Atrial fibrillation – rate control, but how?

So we’ve decided that rate control is the best way forward for you – but how do we achieve it?

The mainstay is medication and there are different types that can be used.

First line are beta blockers such as bisoprolol.  These are usually very safe and well tolerated.  They can be taken safely for many years.  They can even be used in pregnancy!  The most frequent side effects that people complain to me about is feeling cold, and the second is that they can make some people feel tired.  Some people complain about vivid dreams.  There are of course other side effects noted in the sheet you get with the medicines, but these are the ones I hear about in the real world!

If these don’t suit a calcium channel antagonist such as diltiazem can be helpful.  Again, usually well tolerated and safe.

If these don’t do the trick or can’t be used because of low blood pressure then digoxin is a reasonable choice.  This is a drug that is made from the foxglove and has been known about for centuries.  It is quite effective, but oftentimes doesn’t control the heart rate on exercise so isn’t so suitable for active people.  I’ve linked a short film made a long time ago by one of my mentors Dr Holman for the Wellcome foundation.

Occasionally of course combination of these medications need to be used.  The alternative is a “pace and ablate” strategy where a pacemaker is implanted and the electrical connection between the atria and the ventricles is ablated thus making the ventricular rate controlled by the pacemaker.  This can be very effective in dealing with symptoms because it results in a regular pulse as well as a normal heart rate.



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