Introduction to rate control for atrial fibrillation

The aim of rate control for patients with atrial fibrillation is to prevent haemodynamic deterioration by controlling ventricular rate; this is a reasonable approach in patients who are symptomatic or who have a high ventricular rate (regardless of symptoms). Aim for a resting heart rate of less than 110 beats per minute; however, once attained, breakthrough rapid episodes of atrial fibrillation can still occur.

Drugs used for rate control areHindricks, 2021:

• beta blockers
• nondihydropyridine calcium channel blockers
• digoxin
• amiodarone.

The choice of drug is influenced by the patient’s comorbidities and possible adverse effects; for example, starting a beta blocker in a patient with atrial fibrillation that is secondary to pulmonary embolism could cause deterioration. Combination drug therapy may be required to achieve rate controlHindricks, 2021.

Oral therapy is usually sufficient to achieve rate control; intravenous therapy is rarely necessary but useful if a rapid onset of effect is required for urgent rate control. The initial drug(s) used can often be continued for long-term rate controlHindricks, 2021NHFA CSANZ Atrial fibrillation guideline working group, 2018.

For patients with atrial fibrillation whose rate is not adequately controlled by drugs, consider pacemaker insertion followed by atrioventricular (AV) node ablationHindricks, 2021—seek specialist advice.