Rate Control for

Atrial Fibrillation

AA Ayu Dwi Adelia Yasmin

Cardiovascular Department
Udayana University-Sanglah Hospital
Atrial Fibrillation
• AF → uncoordinated atrial activation without
effective atrial contraction.

• P waves → fibrillatory waves → irregular ventricular

response & various amplitude of QRS complexes.

• Most common sustained arrhythmia in humans →

increase morbidity and mortality.

• Increased prevalence.

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Haemodynamic Consequences

• Loss of atrial contraction and atrioventricular

synchrony.

• Irregular ventricular response.

• Rapid heart rate.

• Thromboembolism.

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Rate Control in AF

• Adequate control of the ventricular response during

AF → improve symptoms & avoid Tachycardia-
mediated cardiomyopathy.

• Important for HR at rest & with exertion.

• More cost-effective than rhythm control.

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Heart Rate Targets in AF

• AFFIRM trial
• Resting HR ≤80 bpm or averaging ≤100 bpm on
ambulatory monitoring, without a rate >100% of the
maximum age-adjusted predicted exercise heart rate

• RACE II trial:
• Lenient (resting HR <110 bpm) vs strict (resting HR <80
bpm).

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Negative Chronotropic Drugs vs
Electrophysiological Intervention

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Which Agents for Which Patients?

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Individual Patient Considerations

• Symptoms.
• Comorbidities.
• Valvular vs non valvular.
• LV systolic dysfunction.
• Heart failure.
• Pre-excitation.

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Rate Control Agents

Beta blockers
Calcium Channel
Metoprolol, Bisoprolol, Blockers
Atenolol, Esmolol,
Verapamil & Diltiazem
Nebivolol, Carvedilol

Digitalis Glycosides Others

Digoxin & Digitoxin Amiodarone

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Non Pharmacological Approach

• Ablation of AV node/His Bundle and implantation of

VVI Pacemaker.
• Tachycardia-induced cardiomyopathy.
• Refractory to medical therapy.
• Elderly.

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Gelder et al., Lancet, 2016; 388: 818-28 17
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