Heart rate control is only suitable for some AF patients; this section suggests when heart rate control may be appropriate.
Antiarrhythmic drugs (AADs) are not routinely used for asymptomatic AF or by people with permanent AF who did not undergo rhythm control.5,6 AADs also have important contraindications and cause dose-limiting adverse events. Nevertheless, AADs can re-establish normal heart rate and left ventricular function in AF patients with cardiomyopathy and may increase the likelihood of successful electrical cardioversion if initial attempts were unsuccessful.6
The choice of AAD for ventricular rate control depends on the patient’s lifestyle and comorbidities.20 The ESC/EHRA guidelines recommend beta-blockers, digoxin or the calcium channel blockers diltiazem or verapamil to control heart rate in AF patients with left ventricular ejection fraction (LVEF) of at least 40% (Figure 14). The guidelines suggest beta-blockers with or without digoxin in AF patients with LVEF less than 40%. Amiodarone may be appropriate for acute rate control in patients with haemodynamic instability or severely depressed LVEF.5
The ESC/EHRA guidelines suggest a resting heart rate of less than 110 beats per minute as the initial heart rate target for rate control therapy. If a single AAD does not adequately reduce heart rate, the guidelines suggest combination therapy.5