Chronic atrial fibrillation: a systematic review of medical heart rate control management
Abstract
OBJECTIVE: Recent guidelines by the National Institute for Health and Clinical Excellence (NICE) and the American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) on rate control management for chronic atrial fibrillation have relegated digoxin to second line treatment, recommending instead the use of beta-blockers or rate limiting calcium antagonists as first line treatment. The objective of this review is to assess the efficacy of these drugs in controlling heart rate, and in improving symptoms and exercise tolerance. DATA SOURCES: We electronically searched the Medline, Embase and Cochrane databases, hand searched journals and relevant bibliographies for articles. SELECTION OF STUDIES: We included all study designs evaluating or comparing oral digoxin, beta-blockers and calcium antagonists, alone or in combination, for rate control in chronic atrial fibrillation. 46 studies satisfied our inclusion and quality criteria. RESULTS: Published studies are small and too heterogeneous to be quantitatively combined. Descriptive synthesis of the data shows little evidence that monotherapy with beta-blockers or calcium antagonists improves symptoms or exercise capacity in patients with chronic atrial fibrillation. Instead it is associated with dose related side effects. CONCLUSION: Based on the limited data available, we conclude that the combination of digoxin with either a beta-blocker or calcium antagonist should be first line management in patients with chronic atrial fibrillation.
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Compared with stroke prevention and rhythm control, very little robust evidence exists to inform the best type and intensity of rate control treatment, with the majority of data derived from short-term crossover trials and observational studies.
“Compared with stroke prevention and rhythm control, very little robust evidence exists to inform the best type and intensity of rate control treatment, with the majority of data derived from short-term crossover trials and observational studies.41,[526][527][528]”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [526]
Verapamil or diltiazem can improve arrhythmia-related symptoms.
“Verapamil or diltiazem can improve arrhythmia-related symptoms, 526 in comparison with beta-blockers, which reduced exercise capacity and increased B-type natriuretic peptide in one small trial of low-risk patients with preserved LVEF.542”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [526]
Comparisons with other rate control therapies are based on small, short-duration studies that identify no or marginal differences in exercise capacity, quality of life, or LVEF compared to digoxin.
“Comparisons with other rate control therapies are based on small, short-duration studies that identify no or marginal differences in exercise capacity, quality of life, or LVEF compared to digoxin.526,[554][555][556][557][558]”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [526]
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2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS
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- Authors
- Nikolaidou, T., & Channer, K. S.
- Affiliations
- Royal Hallamshire Hospital (GB)
- Corresponding author
- Nikolaidou, T
- ORCID
- Nikolaidou, T
- Venue
- Postgraduate Medical Journal
- Publisher
- Oxford University Press (OUP)
- Published
- 2009-06-01
- Volume
- 85
- Issue
- 1004
- Pages
- 303-312
- ISSN
- 0032-5473 (ISSN-L)
- 1469-0756
- OpenAlex
- W2102658369
- Cited by
- 48
- References
- 66
- Citations by year
- 2026: 2 · 2024: 3 · 2023: 4 · 2021: 6 · 2020: 4 · 2019: 2 · 2018: 4 · 2017: 5 · 2016: 7 · 2014: 2 · 2012: 3
- FWCI
- 0.45
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Postgraduate Medical Journal (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart rate and cardiovascular health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Keywords
- chronic atrial fibrillation, rate control, digoxin, beta-blockers, calcium channel blockers, combination therapy, exercise tolerance, symptom improvement, adverse drug reactions, first-line therapy
- MeSH terms
- Adrenergic beta-Antagonists, Anti-Arrhythmia Agents, Atrial Fibrillation, Calcium Channel Blockers, Chronic Disease, Clinical Trials as Topic, Digoxin, Drug Therapy, Combination, Humans
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