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Rate control in the medical management of atrial fibrillation
  1. A J Camm1,
  2. I Savelieva1,
  3. G Y H Lip2,
  4. on behalf of the Guideline Development Group for the NICE clinical guideline for the management of atrial fibrillation
  1. 1Division of Cardiac & Vascular Sciences, St George’s University of London, London, UK
  2. 2University Department of Medicine, City Hospital, Birmingham, UK
  1. Correspondence to:
    A J Camm
    British Heart Foundation Professor, St George’s University of London, Cranmer Terrace, London SW17 0RE, UK; jcamm{at}sgul.ac.uk

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Two main strategies are available for management of atrial fibrillation: rate control and rhythm control.

The aims of heart rate control in atrial fibrillation are to minimise symptoms associated with excessive heart rates and to prevent tachycardia-associated cardiomyopathy.1 Rate control involves the use of negatively chronotropic drugs or electrophysiological/surgical interventions to reduce the rapid ventricular rate often found in patients with atrial fibrillation.2 Although the atria continue to fibrillate, this strategy is considered an effective treatment as it can improve symptoms and reduce the risk of associated morbidity. However, the risk of stroke and occurrence of thromboembolic events occurring is reduced by giving antithrombotic drugs.

Rhythm control involves the use of electrical or pharmacological cardioversion or electrophysiological/surgical interventions to convert the arrhythmia associated with atrial fibrillation to normal sinus rhythm. Patients who have been successfully cardioverted are generally given antiarrhythmic drugs for the long term to help prevent the recurrence of atrial fibrillation. Rhythm control strategies also require the appropriate antithrombotic treatment to reduce the risk of stroke and thromboembolism.

WHAT CONSTITUTES ADEQUATE RATE CONTROL?

The optimal heart rate in atrial fibrillation is not known. Current guidelines define adequate rate control in atrial fibrillation as maintenance of the ventricular rate response between 60 and 80 beats/min at rest and between 90 and 115 beats/min during moderate exercise.3 A consensus statement has suggested a target heart rate of <90 at rest and <180 bpm during exercise in patients with atrial fibrillation.4 However, no controlled clinical trials have validated these target rates for preventing all-cause cardiovascular morbidity or mortality, and such recommendations may be flawed. Few data exist that define the most robust method for the assessment of rate control.

Adequate rate control may encompass more than the prevention of fast ventricular rates. However, few systematic studies have explored the effect of rate-slowing …

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