Control Heart Rate, Treat A-Fib

Heart rate monitor
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If you have atrial fibrillation, it might turn out that the optimal treatment in your case is the “rate-control method,” a treatment strategy that may at first sound counter-intuitive. With the rate-control approach, the atrial fibrillation is allowed to persist, and treatment is aimed at eliminating your symptoms by keeping your heart rate from becoming too fast, and taking additional steps to reduce your risk of stroke. 

The other approach to treating atrial fibrillation — the rhythm-control approach, which is aimed at restoring and maintaining a normal heart rhythm — may on the surface seem much better. However, because of the risks of the rhythm-control method, and because it has relatively little chance of working in many people, the rate-control method is often preferred.

Why Is the Rate-Control Method Often Preferred?

In many people with atrial fibrillation, and in most people who have chronic or persistent atrial fibrillation (that is, they have been in atrial fibrillation all or most of the time for many weeks or months), results tend to be much better with the rate-control approach.

To a large extent, this is because rhythm control tends to be rigorous, inconvenient, entails a relatively high risk of side effects, and (especially in people with frequent or chronic atrial fibrillation), it tends to be ineffective. Furthermore, most people who are treated with rate control do quite well; clinical studies show that their outcomes are at least as good, if not better, than for those in whom rhythm control is attempted.

Controlling Heart Rate in Atrial Fibrillation

The rate-control approach to atrial fibrillation has two goals — to control the heart rate, and to prevent blood clots and stroke.

In most people with atrial fibrillation, symptoms are directly caused by the rapid heart rate that usually accompanies this arrhythmia. In fact, as long as the heart rate is controlled, most people with atrial fibrillation can lead essentially normal lives, despite the persistence of their arrhythmia. Generally, control of the heart rate can be achieved by giving beta blocking drugs, often along with calcium channel blockers. In addition, digoxin is often useful in slowing the heart rate in atrial fibrillation.

All three of these drugs work by slowing the conduction of the electrical impulse through the AV node, which reduces the number of impulses that reach the ventricles - thus reducing the heart rate. In the large majority of people with atrial fibrillation, the heart rate can be adequately controlled with some combination of these drugs.

In some cases, however, the heart rate remains rapid enough to cause persistent symptoms despite therapy. In these instances, the heart rate can be readily controlled by a special ablation procedure aimed at damaging the AV node. In this procedure, a special catheter ablates the node by cauterizing or freezing it.

Ablating the AV node prevents the rapid electrical impulses produced by atrial fibrillation from reaching the ventricles, so the heart rate becomes very slow. In fact, AV node ablation usually results in heart block, which often leads to a heart rate that is too slow. So AV node ablation always requires the insertion of a permanent pacemaker. Because modern pacemakers can change the rate at which they pace, depending on your activity level, the AV node ablation-plus-pacemaker option gives the person with atrial fibrillation heart rates — both at rest and during exercise — that simulate the heart rates of people with normal heart rhythms.

While AV nodal ablation may seem a somewhat drastic approach to controlling the heart rate, it almost always results in a remarkable improvement in symptoms for patients with persistent atrial fibrillation and in whom other measures have failed.

Preventing Blood Clots

Treatment to prevent blood clots from forming in the atria is a critical step in anyone who has atrial fibrillation. Most people with atrial fibrillation should be on therapy with an anti-coagulation drug(drugs that "thin" the blood to prevent blood clots) to prevent strokes. Until very recently Coumadin was the only good option available, but using Coumadin safely and effectively can be a difficult thing to accomplish. Fortunately, newer and easier-to-use options (the NOAC drugs) for effective anti-coagulation in atrial fibrillation have recently become available.

A Word From Verywell

While it may not be intuitive, the rate-control approach to treating atrial fibrillation is usually quite effective at eliminating symptoms, and greatly reduces the risk of stroke. Until better methods are developed for getting rid of atrial fibrillation and restoring a normal heart rhythm, the rate-control approach is the better choice for a majority of people who have this arrhythmia.

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Article Sources

  • Dorian P. Rate Control in Atrial Fibrillation. N Engl J Med 2010; 362:1439.

  • January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:2071.

  • Wann LS, Curtis AB, January CT, et al. 2011 ACCF/AHA/HRS Focused Update on the Management of Patients with Atrial Fibrillation (Updating the 2006 Guideline): a Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011; 57:223.