From the Guidelines
For rate control in atrial fibrillation, I recommend starting with a beta-blocker, such as metoprolol, or a calcium channel blocker like diltiazem or verapamil, as these are recommended as first-choice drugs in patients with AF and LVEF >40% to control heart rate and reduce symptoms 1. The choice of medication should be based on the patient's comorbidities and symptoms.
- Beta-blockers are often preferred first-line agents, especially in patients with heart failure or coronary artery disease.
- For acute rate control in the hospital setting, intravenous metoprolol or diltiazem can be administered.
- The target heart rate should be less than 110 beats per minute at rest.
- Dose adjustments should be made based on the patient's response and tolerance.
- Digoxin can be considered as an add-on therapy, particularly in patients with heart failure, but is less effective as monotherapy, especially during exercise. Key considerations include:
- Monitoring of heart rate, blood pressure, and symptoms is essential.
- Medication choice should be tailored to the patient's comorbidities, with beta-blockers avoided in severe asthma and calcium channel blockers avoided in heart failure with reduced ejection fraction. According to the most recent guidelines, beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs in patients with AF and LVEF >40% to control heart rate and reduce symptoms 1. In patients with AF and LVEF ≤40%, beta-blockers and/or digoxin are recommended to control heart rate and reduce symptoms 1. It is essential to consider the patient's individual needs and adjust the treatment plan accordingly.
From the FDA Drug Label
Digoxin is indicated for the control of ventricular response rate in patients with chronic atrial fibrillation.
- Rate control in atrial fibrillation can be started with digoxin (PO), as it is indicated for the control of ventricular response rate in patients with chronic atrial fibrillation 2.
- It is recommended to use digoxin where possible, with a diuretic and an angiotensin-converting enzyme inhibitor, but the optimal order for starting these drugs cannot be specified.
From the Research
Rate Control in Atrial Fibrillation
To start a patient on rate control with atrial fibrillation, several factors should be considered, including symptoms and clinical characteristics.
- The choice of rate control depends on the individual patient, but common options include:
- β blockers, alone or in combination with digoxin
- non-dihydropyridine calcium-channel blockers (not in heart failure) 3
- β blockers are effective in maintaining sinus rhythm and controlling the ventricular rate during atrial fibrillation, and may be considered as first-line agents in the management of patients with atrial fibrillation 4
- Digoxin is least effective, but a reasonable choice for physically inactive patients aged 80 years or older, in whom other treatments are ineffective or are contraindicated, and as an additional drug to other rate-controlling drugs, especially in heart failure when instituted cautiously 3
- Atrioventricular node ablation with pacemaker insertion for rate control should be used as an approach of last resort but is also an option early in the management of patients with atrial fibrillation treated with cardiac resynchronisation therapy 3
Treatment Goals
The goals of rate-control therapy are to:
- reduce symptoms
- improve quality of life
- minimize the development of heart failure
- prevent thromboembolic complications 5
- Several approaches to control rate during atrial fibrillation are available, including pharmacological rate control and atrioventricular nodal ablation with pacemaker implantation 5
Pharmacological Rate Control
Pharmacological rate control options include:
- β blockers, such as metoprolol CR/XL, which are effective in controlling the ventricular rate at rest and during exercise 4
- calcium channel blockers, which cause a similar reduction in resting heart rate to digoxin and β blockers 6
- digoxin, which is occasionally effective in improving exercise tolerance, but may have limited efficacy in controlling ventricular rate 6 3