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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e59 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation complications during long-term follow-up, likely due to a high rate of development of new-onset AF. 7 RATE CONTROL 7.1 Broad Considerations for Rate Control Recommendations for Broad Considerations for Rate Control Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 B-NR 1 In patients with AF, SDM with the patient is recom- mended to discuss rhythm- versus rate-control strategies (taking into consideration clinical presentation, comorbidity burden, medication profile, and patient preferences), discuss therapeutic options, and for assessing long-term benefits.1–3 2a B-R 2 In patients with AF without HF who are candidates for select rate-control strategies, heart rate target should be guided by underlying patient symptoms, in general aiming at a resting heart rate of <100 to 110 bpm.2,4–6 Synopsis Rate control is a suitable strategy for many patients with AF.1,3 A solitary randomized trial has evaluated the optimal heart rate among patients with AF. In the RACE II study (Rate Control Efficacy in Permanent Atrial Fibrillation: A Comparison Between Lenient Versus Strict Rate Control II), 614 patients with permanent AF were randomly assigned to either lenient rate control (resting heart rate <110 bpm) or strict rate control (heart rate, <80 bpm). A difference was not seen regarding either the primary composite outcome of death from cardiovascular causes, hospitalization for HF, stroke, systemic embolism, bleeding, and lifethreatening arrhythmic events (absolute difference of –2.0 percentage points [90% CI, –7.6 to 3.5; P<0.001] for the noninferiority margin)2 or the secondary outcome of QOL7 at 3 years. These data suggest heart rate control intensity is not a central determinant of clinical outcomes. However, interpretation is limited by a difference of only 10 bpm between study groups attributable to the proportion of patients assigned to strict control who did not achieve target rate control (32.6%; n=98/301) and because 78% of lenient rate control participants having heart rate <100 bpm.8 In addition, because patients with HF were underrepresented, whether the results can be extrapolated to those with HF is unknown. Nonrandomized data focused on target heart rate among outpatients,4,9,10 as well as those with HF,5,11–16 are divergent. Recommendation-Specific Supportive Text 1. Rate- and rhythm-control strategies have com- parable clinical outcomes in many patients with AF. In the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) study, rate control was comparable to cardioversion and antiarrhythmic drugs regarding survival (HR, 1.15 [95% CI, 0.99-1.34]; P=0.08).1 In the HOT CAFE (How to Treat Chronic Atrial Fibrillation) trial, rate control was comparable to cardioversion and use of antiarrhythmic drugs with respect to a composite endpoint of all-cause mortality, number of thromboembolic events, or major bleeding (OR, 1.98 [95% CI, 0.28-22.3]; P>0.71).6 In a meta-analysis of randomized trials and observational studies comparing rhythm with rate control, management strategies were comparable with respect to all-cause (OR, 1.34 [95% CI, 0.89-2.02]) and cardiac mortality (OR, 0.96 [95% CI, 0.77-1.20]) as well as stroke (OR, 0.99 [95% CI, 0.76-1.30]).3 Although selection of a rhythm-control therapy within a year of AF diagnosis may be considered to reduce the risk of adverse cardiovascular outcomes,17 early rate control may still be appropriate as a function of clinical presentation, comorbidity burden, medication profile, and patient preferences. In this context, providers should partner with their patients to select a value-concordant approach within an SDM framework. 2. In RACE II, rate-control intensity (target resting heart rate, <110 bpm versus <80 bpm) did not influence cardiovascular morbidity or mortality.6,18 Rate control (AFFIRM: goal heart rate, ≤80 bpm at rest and ≤110 bpm during a 6-minute walk test; HOT CAFE: 70-90 bpm at rest and ≤140 bpm with moderate exercise) has been shown to be comparable to rhythm control in a meta-analysis of 5 trials, yet some limitation of the studies include that most patients had well-tolerated persistent AF or high risk of recurrence, no long-term follow-up, and should not be extrapolated to patients with paroxysmal AF, highly symptomatic, or patients with HF.1 Observational data among outpatients and those with HF are conflicting.4 In the ORBIT-AF trial, increasing heart rate was associated with higher all-cause mortality9 and incident HF.10 Whether a lenient rate-control strategy may be safely and effectively used in patients with heart failure with preserved ejection fraction (HFpEF)5,14 or reduced fraction11–13,15,16 has also shown conflicting results. Other populations that may benefit from a low heart rate goal include those with rate-related cardiac dysfunction,19 ICDs,20 cardiac resynchronization therapy,21 and tachycardia-bradycardia form of sick sinus syndrome22 (Table 20). 7.2 Specific Pharmacological Agents for Rate Control The overall goals for rate control in patients with both acute and chronic AF with a rapid ventricular response center on control of symptoms and the risk of developing Downloaded from http://ahajournals.org by on October 7, 2026