A systematic review 1 to determine the most efficacious drugs for controlling ventricular rate in patients with atrial fibrillation (AF) included 45 studies with a total of 2 059 subjects. Heart rate was reduced significantly (both at rest and with exercise) in 5 studies of verapamil and 5 of diltiazem compared with placebo. Exercise tolerance was equivalent or improved in 6 of 7 comparisons. Beta-blocker compared with placebo was efficacious for control of resting heart rate in 7 of 12 comparisons. All 9 comparisons demonstrated good heart rate control with beta-blockers during exercise, although exercise tolerance was compromised in 3 of 9 comparisons. Digoxin administered alone slowed the resting heart rate more than placebo in 7 of 8 studies, but it did not significantly slow the rate during exercise in 4 studies.
According to the 2024 ESC Guidelines for the management of atrial fibrillation 2, beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs to control heart rate and reduce symptoms in patients with AF and left ventricular ejection fraction (LVEF) > 40%.In patients with AF and LVEF HASH(0x2fdd780) 40%, beta-blockers and/or digoxin are recommended to control heart rate and reduce symptoms. Beta-blockers, specifically beta-1 selective adrenoreceptor antagonists, are often first-line rate-controlling agents largely based on their acute effect on heart rate and the beneficial effects demonstrated in patients with chronic heart failure with reduced ejection fraction (HFrEF).
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