12
Treatment
Table 8. Rate Control
Recommendations COR LOE
Control of the ventricular rate using a beta blocker
or nondihydropyridine calcium channel antagonist is
recommended for patients with paroxysmal, persistent, or
permanent AF.
I B
IV administration of a beta blocker or nondihydropyridine
calcium channel blocker is recommended to slow ventricular
heart rate in the acute setting in patients without pre-
excitation. In hemodynamically unstable patients, electrical
cardioversion is indicated.
I B
In patients who experience AF-related symptoms during
activity, the adequacy of heart rate control should be assessed
during exertion, adjusting pharmacological treatment as
necessary to keep the ventricular rate within the physiological
range.
I C
A heart rate control (resting heart rate <80 bpm) strategy is
reasonable for symptomatic management of AF.
IIa B
IV amiodarone can be useful for rate control in critically ill
patients without pre-excitation.
IIa B
AV nodal ablation with permanent ventricular pacing is
reasonable to control heart rate when pharmacological
therapy is inadequate and rhythm control is not achievable.
IIa B
Lenient rate control strateg y (resting heart rate <110 bpm)
may be reasonable as long as patients remain asymptomatic
and LV systolic function is preserved.
IIb B
Oral amiodarone may be useful for ventricular rate control
when other measures are unsuccessful or contraindicated.
IIb C
AV nodal ablation with permanent ventricular pacing should
NOT be performed to improve rate control without prior
attempts to achieve rate control with medications.
III: Harm C
Nondihydropyridine calcium channel antagonists should
NOT be used in patients with decompensated HF as these
may lead to further hemodynamic compromise.
III: Harm C
In patients with pre-excitation and AF, digoxin,
nondihydropyridine calcium channel antagonists, or
intravenous amiodarone should NOT be administered as
they may increase the ventricular response and may result in
ventricular fibrillation.
III: Harm B
Dronedarone should NOT be used to control the ventricular
rate in patients with permanent AF as it increases the risk of
the combined endpoint of stroke, MI, systemic embolism, or
cardiovascular death.
III: Harm B
