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Rate control for atrial fibrillation has been proven to be a reasonable treatment option for certain groups of patients with persistent or permanent atrial fibrillation.1–5 The mainstays of rate control treatment include β-blockers, calcium channel blockers and digoxin. What is surprising is that despite the existence of these drugs for a considerable time (over 200 years in the case of digoxin), we are still not clear which single drug or combination of drugs is optimal. Doubt arises due to the lack of robust data examining this specific issue in the form of large randomised clinical trials. Despite this lack of evidence, guidelines from the National Institute for Health and Clinical Excellence (NICE)6 and the combined forces of the American Heart Association (AHA), American College of Cardiology (ACC) and the European Society of Cardiology (ESC)7 promote monotherapy using drugs other than digoxin as first line treatment. But what is the basis for these recommendations and is this guidance the best advice?
This is not simply a polemical argument. The disadvantages of high heart rates in patients with atrial fibrillation are well documented8 and there is evidence that heart rate slowing and regularisation either through atrioventricular (AV) nodal blocking agents,9 10 restoration of sinus rhythm through left atrial ablation,11 or AV node ablation and permanent ventricular pacing12 can effectively restore or improve left ventricular dysfunction in the “tachycardia–cardiomyopathy” cohort. For those patients not suitable for left atrial ablation or an “ablate and pace” …
Competing interests: None declared.
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