Atrial Fibrillation: Rate Control and Maintenance of Sinus Rhythm

Key points

• NICE NG196: offer RATE control as the first-line strategy for most people with AF — unless AF has a reversible cause, heart failure is thought to be caused by the AF, the AF is new-onset (within 48 hours), it is atrial flutter suitable for ablation, or a rhythm-control strategy is more suitable on clinical judgement.
• Initial rate-control monotherapy: a standard beta-blocker (that is, NOT sotalol) or a rate-limiting calcium-channel blocker (diltiazem — off-label — or verapamil) · base the choice on symptoms, heart rate, comorbidities and preference.
• Digoxin monotherapy only for non-paroxysmal AF when the person does no or very little physical exercise, or when other rate-limiting drugs are unsuitable — it is less effective at controlling rate during exertion.
• AF with concomitant heart failure: follow NG106 — use a beta-blocker and AVOID rate-limiting calcium-channel blockers.
• If monotherapy fails and symptoms are due to poor rate control, use dual therapy with any two of: beta-blocker, diltiazem, digoxin. Do NOT offer amiodarone for long-term rate control.
• Rhythm control agents if that strategy is chosen: a standard beta-blocker first-line, then dronedarone, amiodarone, flecainide or sotalol depending on comorbidity · flecainide only if there is no structural or ischaemic heart disease · amiodarone suits those with left ventricular impairment or heart failure · consider ablation if drugs fail.

Decision points in this pathway

• Any exception to a rate-control-first strategy? (reversible cause · heart failure thought to be caused by the AF · new-onset AF within 48 hours · atrial flutter suitable for ablation · rhythm control more suitable on clinical judgement)
• Non-paroxysmal AF in someone sedentary, or other rate-limiting drugs unsuitable?
• Symptoms persist and are thought to be due to poor ventricular rate control?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.