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41.13 Rate control: medical therapy
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Published:July 2018
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Abstract
Control of the heart rate (rate control) is central to atrial fibrillation management, even for patients who ultimately require control of the rhythm. The choice of rate control depends on symptoms and clinical characteristics of the patient, but for all patients with atrial fibrillation, rate control is part of the management. Choice of drugs is patient dependent and driven by the patient-specific rate–symptom relationship as well as associated conditions. Beta blockers, alone or in combination with digoxin, or non-dihydropyridine calcium channel blockers effectively lower the heart rate. Digoxin is least effective, but a reasonable choice for older, physically inactive patients, in whom other therapies are ineffective or contraindicated, and as an additional drug, especially in systolic heart failure. Institution of all rate control drugs should be performed cautiously. Atrioventricular node ablation with pacemaker insertion for rate control should be the approach of last resort. Catheter ablation of atrial fibrillation, however, should be considered before atrioventricular node ablation. No one formula can integrate the best approach to a specific drug or the effects of therapeutic combinations, but one important message is that a lenient approach to rate control is easy, safe, and effective in many patients and should be considered as the initial approach. A stricter rate control approach is adopted when symptoms persist or deterioration of the left ventricular function occurs. Although rate control is the top priority and one of the first management issues for all patients with atrial fibrillation, and has been studied extensively, many issues remain.
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