Rate Control in Atrial Fibrillation

Abstract

Controlling the ventricular rate during both paroxysmal and persistent atrial fibrillation (AF), initially with digitalis preparations and subsequently with β-blockers and calcium channel blockers, has been a mainstay for the management of this arrhythmia for many years. With the advent of a wide range of pharmacological and nonpharmacological approaches for maintaining sinus rhythm, rhythm control strategies have entered widespread clinical use in selected subsets of symptomatic patients. Despite the availability of these rhythm control strategies, however, rate control of AF remains an important and useful approach for a large number of patients, especially those with little or no symptoms from the arrhythmia once the ventricular rate has been controlled. This review discusses the relative risks and benefits of rate versus rhythm control strategies, describes the targets and available methods for rate control, and highlights special considerations for ventricular rate control when cardiac resynchronization therapy (CRT) is used in patients with AF. Among the most important decisions that must be made by a patient and care provider when choosing a treatment plan for AF is the choice between rate and rhythm control. Rate control is typically a simpler strategy than rhythm control, involving the use of generally less toxic medications and fewer medical procedures, although rate control strategies can result in adverse drug side effects and toxicities and, in some cases, may require interventions such as pacemaker implantation and atrioventricular (AV) nodal ablation. Rhythm control strategies typically involve potentially riskier antiarrhythmic medications or invasive procedures such as catheter ablation or surgery, but, when successful, provide the benefits of sinus rhythm. ### Randomized Trials of Rate versus Rhythm Control Several large randomized, controlled clinical trials have been performed to compare the risks and benefits of rate versus pharmacological rhythm control strategies in patients with AF. Among these are the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM), Rate Control Versus …