Atrial fi brillation 2 Rate control in atrial fi brillation

Control of the heart rate (rate control) is central to atrial fi brillation management, even for patients who ultimately require control of the rhythm. We review heart rate control in patients with atrial fi brillation, including the rationale for the intervention, patient selection, and the treatments available. The choice of rate control depends on the symptoms and clinical characteristics of the patient, but for all patients with atrial fi brillation, rate control is part of the management. Choice of drugs is patient-dependent. β blockers, alone or in combination with digoxin, or nondihydropyridine calcium-channel blockers (not in heart failure) eff ectively lower the heart rate. Digoxin is least eff ective, but a reasonable choice for physically inactive patients aged 80 years or older, in whom other treatments are ineff ective or are contraindicated, and as an additional drug to other rate-controlling drugs, especially in heart failure when instituted cautiously. Atrioventricular node ablation with pacemaker insertion for rate control should be used as an approach of last resort but is also an option early in the management of patients with atrial fi brillation treated with cardiac resynchronisation therapy. However, catheter ablation of atrial fi brillation should be considered before atrioventricular node ablation. Although rate control is a top priority and one of the fi rst management issues for all patients with atrial fi brillation, many issues remain.