Despite major advances in atrial fibrillation (AF) catheter ablation, rate control remains the most widely used management strategy for AF in the general population. In addition to its use as a primary approach to control symptoms and prevent complications of AF, rate control is often a necessary complement to rhythm-control strategies, especially with antiarrhythmic drugs. The value of rate-control therapy is supported by several large randomized clinical trials showing no difference in major cardiovascular outcomes between rate-control and rhythm-control strategies with currently available therapeutic approaches (antiarrhythmic drugs and/or catheter ablation). Despite its extensive use, the rational basis for rate-control therapy is underemphasized in clinical teaching and practice. In this article, we aim to provide evidence-based thoughts on important practical aspects of rate-control therapy in AF by reviewing 5 clinically relevant issues. We (1) highlight the pharmacological differences between the mechanisms of action of β-blockers and Ca2+-channel blockers for AF rate control and the practical implications for therapeutic decision making; (2) review the controversies surrounding the use of digoxin for AF rate control in the light of recently published work; (3) discuss the evidence for rate-control heart rate targets in patients with AF and preserved left-ventricular function; (4) examine how heart rate targets may differ in patients with heart failure and reduced vs preserved left-ventricular ejection fraction and the importance of heart-rate lowering for the effectiveness of cardiac resynchronization therapy in patients with heart failure and AF; (5) discuss the relationship between AF, exercise capacity, and rate-controlling drug class.
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