From the Guidelines
Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs for rate control in patients with atrial fibrillation (AFib) and left ventricular ejection fraction (LVEF) >40%. According to the 2024 ESC guidelines for the management of atrial fibrillation 1, these medications are effective in controlling heart rate and reducing symptoms in patients with AFib.
Key Considerations
- The choice of medication depends on the patient's comorbidities, with beta-blockers preferred in patients with heart failure or coronary artery disease, and calcium channel blockers may be better for patients with COPD or asthma.
- The target heart rate is typically less than 110 beats per minute at rest for most patients with persistent atrial fibrillation.
- In patients with AFib and LVEF ≤40%, beta-blockers and/or digoxin are recommended to control heart rate and reduce symptoms 1.
Medication Options
- Beta-blockers: metoprolol, atenolol, or bisoprolol
- Calcium channel blockers: diltiazem or verapamil
- Digoxin: may be used in combination with beta-blockers in patients with LVEF ≤40% These medications work by slowing conduction through the atrioventricular node, which limits the ventricular response to the rapid atrial impulses characteristic of atrial fibrillation, thereby improving symptoms and cardiac function 1.
From the FDA Drug Label
Data are not available to establish the appropriate resting or exercise target rates that should be achieved Atrial Fibrillation: Doses of digoxin used for the treatment of chronic atrial fibrillation should be titrated to the minimum dose that achieves the desired ventricular rate control without causing undesirable side effects.
The FDA drug label does not answer the question.
From the Research
First Line Treatment for Rate Control in Atrial Fibrillation
The first line treatment for rate control in atrial fibrillation (AFib) is a topic of discussion among various studies.
- Beta-blockers, such as metoprolol, are considered effective in maintaining sinus rhythm and controlling the ventricular rate during AFib, with a low risk of proarrhythmia 2.
- Calcium channel blockers, such as diltiazem, are also considered a preferred agent for rate control in AFib due to their quick onset and minimal side effects 3, 4.
- The choice of agent may depend on the individual patient and clinical situation, with considerations for comorbidities and potential side effects 5, 4.
- Studies have shown that both beta-blockers and calcium channel blockers can be effective in controlling the ventricular rate, but the choice of agent may impact exercise capacity and levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) 6.
Comparison of Agents
- Diltiazem and verapamil have been shown to preserve exercise capacity and reduce levels of NT-proBNP compared to beta-blockers such as metoprolol and carvedilol 6.
- Metoprolol and verapamil have been compared in terms of time to achieve rate control, with verapamil showing a faster time to control 3.
- The efficacy and safety of calcium channel blockers and beta-blockers for rate control in AFib have been evaluated in several studies, with both types of agents showing effectiveness and safety 5, 3, 4.