Atrial fibrillation: ventricular rate control
Reducing the ventricular response in atrial fibrillation to 80–110 bpm at rest (lenient control per RACE II) or under 80 (strict control with symptoms or HFrEF). First-line per ESC AF 2024: beta-blockers and non-dihydropyridine calcium antagonists (verapamil, diltiazem). Digoxin is an option in sedentary patients and in HFrEF.
ICD-10 I48.92 drugs
Also known as: AF rate control
Drugs used for this condition
- BAmiodaroneThird line · Class III antiarrhythmics (Vaughan Williams)Per ESC AF 2024, amiodarone is not used as first- or second-line for long-term rate control – extracardiac toxicity (pulmonary fibrosis, thyroid dysfunction, hepatotoxicity, corneal deposits) makes the risk/benefit unfavourable without arrhythmic threat. IV amiodarone is used acutely in fast-AF with haemodynamic instability in HF patients where beta-blockers and non-dihydropyridine calcium antagonists are contraindicated. Whenever amiodarone is used, monitor thyroid, lung, and liver function. The interactions with digoxin (amiodarone raises its levels, toxicity risk) and warfarin (increased anticoagulation, bleeding risk) matter especially in AF, where these drugs are often co-prescribed.
- BDigoxinSecond line · Cardiac glycosides (digitalis)Per ESC AF 2024, digoxin is an option for ventricular rate control in sedentary patients, HFrEF, or intolerance to beta-blockers and non-dihydropyridine calcium antagonists. First-line in AF with preserved EF: beta-blockers (metoprolol, bisoprolol, carvedilol) and verapamil/diltiazem when beta-blockade is contraindicated. Digoxin works at rest but does not control rate during exertion – monotherapy is insufficient in active patients. Often combined with a beta-blocker in HFrEF.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit