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Atrial fibrillation - Management
Which initial drug treatment should I offer for rate control of atrial fibrillation?
- Offer a beta-blocker or rate-limiting calcium-channel blocker (diltiazem or verapamil), unless this is contraindicated.
- The choice between beta-blocker and calcium-channel blocker will depend on the person's current medication and comorbidities.
- Diltiazem (off-licensed use for atrial fibrillation) is preferred to verapamil because verapamil has a greater negative inotropic effect on the heart and interacts with digoxin.
- For further information, see the prescribing sections on beta-blockers and calcium-channel blockers.
- If the person has a sedentary lifestyle, digoxin is an alternative option.
- Digoxin is only adequate for older, sedentary people in whom rate control is not needed during exercise.
- For further information, see the prescribing section on digoxin.
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) guideline Atrial fibrillation: national clinical guideline for management in primary and secondary care [National Collaborating Centre for Chronic Conditions, 2006].
After reviewing 12 small randomized or serial crossover trials comparing beta-blockers and calcium-channel blockers for atrial fibrillation (AF), NICE concluded that:
- Both calcium-channel blockers and beta-blockers are more effective than digoxin in controlling heart rate at high levels of physical exertion, but there is no difference during normal daily activities.
- There is no significant difference between calcium-channel blockers and beta-blockers in terms of heart rate control.
Beta-blockers versus calcium-channel blockers
- One crossover study found no difference between diltiazem and atenolol in terms of heart rate over 24 hours or during exercise.
- A second crossover study found no difference between verapamil and atenolol in heart rate at rest or after exercise.
Calcium-channel blockers versus digoxin
- Seven studies found no difference in heart rate between verapamil or diltiazem and digoxin, either at rest or during normal daily activity.
- Seven studies found that verapamil or diltiazem resulted in a lower heart rate during exercise compared with digoxin.
Beta-blockers versus digoxin
- Three studies found no difference in average heart rate between digoxin and beta-blockers while at rest or during normal daily activity.
- Atenolol and labetalol controlled heart rate during exercise more effectively than digoxin.
- One study found that atenolol significantly reduced heart rate compared with digoxin both at rest and after exercise.
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