Atrial fibrillation: how to approach rate control.

The optimal management of atrial fibrillation is of considerable clinical importance, and with the recent publication of four studies suggesting the equivalence of rate and rhythm control strategies, new attention has been focused on rate control. Reasons for rate control include reduction of symptoms and the prevention of tachycardia-mediated cardiomyopathy; yet, evidence-based definitions of optimal rate control are lacking. This article examines an approach to rate control that includes serial assessment of heart rate and symptoms, both at rest and with exertion, and the use of therapy tailored to the individual and modified over time (as no single therapy demonstrates clear superiority). Often, multidrug regimens including digoxin and a calcium channel blocker or beta-blocker are required, and in a minority of patients atrioventricular nodal ablation and pacing are necessary. Several novel therapies currently under development are also discussed.