• Rate-control treatments (beta-blockers, rate-limiting calcium-channel blockers, and digoxin) can be started in primary care, but rhythm-control treatments (such as amiodarone, flecainide, and sotalol) should only be started on specialist advice.
• Consider starting a rate-control drug if the person does not require admission, regardless of whether they are to be managed in primary care or have been referred to a specialist for consideration of rhythm control, if:
• The resting heart rate is 90 beats per minute or more, or
• The heart rate is fast on exertion, resulting in limited exercise tolerance.

Heart rate control

• The National Institute for Health and Clinical Excellence (NICE) recommends that resting heart rate should be controlled to less than 90 beats per minute, and that heart rate on exercise should be controlled to less than 110 beats per minute in people who are inactive or 200 beats per minute minus their age in active people [NICE, 2006].
• A consensus statement from the Royal College of Physicians of Edinburgh suggests a target resting heart rate of less than 90 beats per minute and less than 180 beats per minute during exercise [RCGP, 1999].
• An international guideline states that criteria for rate control vary with age and suggests that ventricular rate should be controlled between 60–80 beats per minute at rest and between 90–115 beats per minute during moderate exercise [Fuster et al, 2006b].
• In clinical practice, the target heart rate during exercise may need to be adjusted depending on the level of exercise the person can manage. For example, a rate of 170 beats per minute is inadequate rate control if the person has only walked up the corridor.

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].

• The aim of rate control is to minimize symptoms associated with excessive heart rate (such as breathlessness) and prevent tachycardia-associated cardiomyopathy [Fuster et al, 2006b].
• Adequate rate control has not been well studied with respect to quality of life, or symptoms or development of cardiomyopathy, and no standard method for assessment of rate control has been established to guide management.
• CKS has outlined the suggested rate control targets from several guideline groups [RCGP, 1999; Fuster et al, 2006a; National Collaborating Centre for Chronic Conditions, 2006].