What are the guidelines for rate control in patients with atrial fibrillation (Afib) (AF)?

Updated: Nov 18, 2019
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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The 2017 American Academy of Family Physicians updated guidelines on the pharmacologic management of newly diagnosed atrial fibrillation (AF) include the following recommendations for patients with AF [153] :

  • Rate control is preferred to rhythm control for most patients with AF, with preferred rate-control options including non-dihydropyridine calcium channel blockers and beta-blockers. However, rhythm control may be considered for some patients on the basis of their symptoms, exercise tolerance, and preferences.

  • Lenient rate control (< 110 beats per minute [bpm]) is preferred over strict rate control (< 80 bpm).

  • Clinicians should discuss stroke and bleeding risks with all patients considering anticoagulation, as well as consider using continuous CHADS2 or CHA2 DS2 -VASc for predicting stroke risk and HAS-BLED for prediction of bleeding risk.

  • Chronic anticoagulation (eg, warfarin, apixaban, dabigatran, edoxaban, rivaroxaban) is recommended unless patients have a low stroke risk (CHADS2 < 2) or have specific contraindications. Selection of the anticoagulation therapy should be based on patient preferences and history.

  • Dual treatment with anticoagulant and antiplatelet therapy is strongly not recommended in most patients with AF.

The 2014 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) guidelines include the following recommendations for control of ventricular rate in patients with AF [1] :

  • Beta-blockers or non-dihydropyridine calcium channel blockers are first-line agents for paroxysmal, persistent or permanent AF.

  • Intravenous (IV) beta-blockers or non-dihydropyridine calcium channel blockers may be used to slow ventricular heart rate in an acute setting in patients without preexcitation; in hemodynamically unstable patients, electrical cardioversion is indicated.

  • Consider IV amiodarone for rate control in critically ill patients without preexcitation if the condition limits the use of beta-blockers or calcium channel blockers.

  • In patients with AF symptoms during activity, assess heart rate control during exertion, adjusting drug treatment as needed.

  • Heart rate control (defined as < 80 bpm at rest) may be considered for less symptomatic patients with AF; a more lenient rate-control strategy (< 110 bpm at rest) is reasonable when patients remain asymptomatic and left ventricular (LV) systolic function is preserved.

  • In patients with inadequate ventricular rate control despite drug therapy, atrioventricular (AV) nodal ablation and pacemaker implantation may be considered.

  • AV nodal ablation should not be performed without prior attempts to achieve rate control with medications.

  • Non-dihydropyridine calcium channel blockers are contraindicated in decompensated heart failure.

  • With preexcitation syndrome and AF, non-dihydropyridine calcium channel blockers, digoxin, and IV amiodarone are contraindicated.

  • Dronedarone should not be used in patients with permanent AF or class III or IV heart failure.

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