For patients with symptomatic atrial fibrillation lasting many weeks, initial therapy may be anticoagulation and rate control while the long-term goal is to restore sinus rhythm.
Rate control may be reasonable initial therapy in older patients with persistent atrial fibrillation who have hypertension or heart disease. For younger individuals, especially those with paroxysmal lone atrial fibrillation, rhythm control may be a better initial approach.

Pharmacological rate control during atrial fibrillation: recommendations


Class I

1) Measurement of the heart rate at rest and control of the rate using pharmacological agents ( either a beta blocker or nondihydropyridine calcium channel antagonist, in most cases ) are recommended for patients with persistent or permanent atrial fibrillation. ( Level of Evidence: B )

2) In the absence of preexcitation, intravenous administration of beta blockers ( Esmolol, Metoprolol, or Propranolol ) or nondihydropyridine calcium channel antagonists ( Verapamil, Diltiazem ) is recommended to slow the ventricular response to atrial fibrillation in the acute setting, exercising caution in patients with hypotension or heart failure. ( Level of Evidence: B )

3) Intravenous administration of Digoxin or Amiodarone is recommended to control the heart rate in patients with atrial fibrillation and heart failure who do not have an accessory pathway. ( Level of Evidence: B )

4) In patients who experience symptoms related to atrial fibrillation during activity, the adequacy of heart rate control should be assessed during exercise, adjusting pharmacological treatment as necessary to keep the rate in the physiological range. ( Level of Evidence: C )

5) Digoxin is effective following oral administration to control the heart rate at rest in patients with atrial fibrillation and is indicated for patients with heart failure, left ventricular dysfunction, or for sedentary individuals. ( Level of Evidence: C )


Class III

1) Digitalis should not be used as the sole agent to control the rate of ventricular response in patients with paroxysmal atrial fibrillation. ( Level of Evidence: B )

2) Catheter ablation of the atrioventricular node should not be attempted without a prior trial of medication to control the ventricular rate in patients with atrial fibrillation. ( Level of Evidence: C )

3) In patients with decompensated heart failure and atrial fibrillation, intravenous administration of a nondihydropyridine calcium channel antagonist may exacerbate hemodynamic compromise and is not recommended. ( Level of Evidence: C )

4) Intravenous administration of Digitalis glycosides or nondihydropyridine calcium channel antagonists to patients with AF and a preexcitation syndrome may paradoxically accelerate the ventricular response and is not recommended. ( Level of Evidence: C )


Classification of recommendations

Class I: Conditions for which there is evidence and/or general agreement that a given procedure/therapy is beneficial, useful, and effective.

Class III: Conditions for which there is evidence and/or general agreement that a procedure/therapy is not useful or effective and in some cases may be harmful.

Source: Circulation, 2006


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