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CLINICAL STATEMENTS AND GUIDELINES January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e60 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation LV systolic dysfunction. In general, nondihydropyridine calcium channel blockers (diltiazem and verapamil) and beta blockers are the standard of care in rate-controlling AF. Nondihydropyridine calcium channel blockers slow conduction through the atrioventricular node and have negative inotropic and chronotropic effects. These agents are useful in ventricular rate control in the absence of preexcitation. They provide reasonable rate control and also improve AF-related symptoms compared with beta blockers.1,2 Beta blockers also slow conduction through the atrioventricular node by blocking beta-1 receptors. Digoxin is a time-honored medication for patients with AF particularly among patients with HFrEF due to its positive inotropic and vagotonic effects. Limited data exist directly comparing rate-control agents, especially in the setting of long-term rate control. Selection of specific agents should consider patient-specific characteristics and response. This section will outline the principles of treatment for acute and long-term rate control. 7.2.1 Acute Rate Control Recommendations for Acute Rate Control Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 B-R 1 In patients with AF with rapid ventricular response who are hemodynamically stable, beta blockers or nondihydropyridine calcium channel blockers (verapamil, diltiazem; provided that EF >40%) are recommended for acute rate control (Figure 17).1–4 2a B-R 2 In patients with AF with rapid ventricular response in whom beta blockers and nondihydropyridine calcium channel blockers are ineffective or contraindicated, digoxin can be considered for acute rate control, either alone or in combination with the aforementioned agents.5–9 2a A 3. In patients with AF with rapid ventricular response, the addition of intravenous magnesium to standard rate-control measures is reasonable to achieve and maintain rate control.10,11 2b B-NR 4 In patients with AF with rapid ventricular response who are critically ill and/or in decompensated HF in whom beta blockers and nondihydropyridine calcium channel blockers are ineffective or contraindicated, intravenous amiodarone may be considered for acute rate control.*12,13 3: Harm B-NR 5 In patients with AF with rapid ventricular response and known moderate or severe LV systolic dysfunction with or without decompensated HF, intravenous nondihydropyridine calcium channel blockers should not be administered.14,15 *Consider the risk of cardioversion and stroke when using amiodarone as a rate-control agent. Synopsis Controlling the ventricular rate in AF with a rapid ventricular response in the acute setting can vary effectiveness for control of symptoms. It can also present challenges, given some agents may or may not be preferable in the context of underlying comorbidities given the myriad of contributing factors. For patients requiring intravenous rate-control agents, hypotension and/or the presence of decompensated HF may limit use of otherwise efficacious agents. In the acute setting, recognizing patients needing emergency cardioversion is important. Recommendation-Specific Supportive Text 1. A randomized, double-blind, placebo-controlled trial investigated the safety and efficacy of continuous intravenous diltiazem infusion for 24-hour heart rate control during AF and AFL. Seventeen of the 23 patients (74%) receiving diltiazem infusion and none of the 21 with placebo infusion maintained a therapeutic response for 24 hours. Over 24 hours, patients receiving diltiazem infusion lost response significantly more slowly than did those receiving placebo infusion. In another RCT, patients were randomly assigned in 1:1:1 ratio to receive intravenous diltiazem, digoxin, or amiodarone for ventricular rate control. At 24 hours, rate control was achieved in 119 of 150 patients (79%). The time to rate control was significantly shorter among patients in the diltiazem group, with the percentage of patients who achieved rate control being higher in the diltiazem group (90%) than the digoxin group (74%) and the amiodarone group (74%). A randomized, parallel, open-label study aimed to investigate esmolol versus verapamil in the acute treatment of AF or AFL. The heart rate significantly declined with esmolol and verapamil. Fifty percent of esmolol-treated patients with new onset of arrhythmias converted to sinus rhythm, whereas only 12% of those who received verapamil converted. Mild hypotension was observed in both treatment groups. 2. The use of intravenous digoxin has been shown to be effective in controlling the rate of rapid AF compared Table 20 Clinical Presentations and Objectives of Heart Rate Control Presentation Objective Symptomatic AF To reduce symptoms Tachycardia-induced cardiomyopathy To improve heart function or reduce the risk of recurrent cardiomyopathy19 ICD use To reduce risk of inappropriate shock20 Cardiac resynchronization therapy use To enhance biventricular pacing, likelihood of myocardial recovery, and/or preservation of function21 Tachycardia-bradycardia form of sick sinus syndrome among those with a pacemaker To reduce the risk of hospitalization22 AF indicates atrial fibrillation; and ICD, implantable cardioverter-defibrillator. Recommendations for Acute Rate Control (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026