How is rate control used to treat atrial fibrillation?

Man with glass of water and box of tablets taking medication

To relieve the symptoms of , it often helps to slow down the fast heart rate with medication. The most common type are called beta blockers. People who don't tolerate them can try other medications.

Atrial fibrillation causes the heart to beat irregularly and too quickly. That can cause an unpleasant racing heart (palpitations) and other symptoms like dizziness and weakness. This fast pulse can damage the heart and cause heart failure over the long term.

It is often enough to slow down the heart rate to relieve the symptoms and take the strain off the heart. This type of treatment is called rate control. That generally involves taking medication, usually beta blockers.

If the symptoms don’t get better by slowing the heart rate down, a different approach known as rhythm control is an option. If it is successful, the heart will beat in its normal rhythm again (sinus rhythm). Special procedures, such as catheter ablation, are generally needed for rhythm control, though. That is why doctors often first recommend rate control to treat . Rhythm control can have more advantages over the long term for some people, though, for example if they already have heart failure or the has only developed recently. Doctors then usually recommend rhythm control right away.

How much does rate control slow down the heart rate by?

The resting pulse is lowered to less than 110 beats per minute using medication. If that doesn’t help to relieve the symptoms, the pulse can be reduced to under 80 beats per minute. That can be done using a higher dose of medication or by taking several different medications. But both of these options can cause more side effects.

What medications are considered?

Finding the most suitable medication depends mainly on any associated medical conditions you might have and the possible side effects of the medication:

  • Beta blockers are used most often to treat and are generally effective and well tolerated. Typical side effects are reduced blood pressure and nausea. Because they can cause breathing difficulties, they are not suitable for people with lung diseases such as asthma or COPD.
  • Calcium antagonists are an effective alternative. The side effects of these products include headache, itching, skin rashes, nausea, and other types of heart rhythm problems. They are also not suitable if the heart's pumping ability is impaired, and they can't be taken together with beta blockers.
  • Cardiac glycosides (digitalis) are usually only prescribed additionally if beta blockers or antagonists alone are not enough to slow down the heart rate. Especially in people with kidney failure, they can cause vision impairment, other heart rhythm disorders, or nausea. Regular blood tests are also necessary.
  • The medication amiodarone is used very rarely – usually only if the other medications were not effective or not tolerated, and other measures are not an option. Possible side effects include trembling, impaired vision, skin, thyroid and circulation problems, and heart rhythm disorders.

What else is important?

Even though the medication makes the heart beat more slowly, the may still continue. That can cause blood clots. A stroke is possible if a blood clot passes through the blood into the brain. That is why anticoagulants are also used to reduce the risk of stroke.

Besides medication, it is important to have a healthy lifestyle to get the heart to beat more slowly. The most helpful things you can do are not drink alcohol, get enough exercise, avoid being overweight, and not smoke. Associated medical conditions that can cause a fast heart rate should be treated, such as sleep apnea.

Are there other ways of slowing down the heart rate?

In rare cases, surgery is used to slow down the heart rate. Part of the heart’s electrical conduction system, the AV node, is destroyed (ablated). That means that no more signals are sent from the atria to the ventricles. But then a pacemaker is needed to make sure the ventricles beat regularly. This treatment is only an option if the heart rhythm problem can’t be treated any other way.

Hindricks G, Eckardt L, Gramlich M et al. Kommentar zu den Leitlinien (2020) der ESC zur Diagnose und Behandlung von Vorhofflimmern. Kardiologe 2021; 15: 354-363.

Hindricks G, Potpara T, Dagres N et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42(5): 373-498.

Kasper DL, Fauci AS, Hauser SL et al. Harrison's Principles of Internal Medicine. New York: McGraw-Hill; 2015.

Kirchhof P, Camm AJ, Goette A et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med 2020; 383(14): 1305-1316.

Marrouche NF, Brachmann J, Andresen D et al. Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med 2018; 378(5): 417-427.

National Institute for Health and Care Excellence (NICE). Atrial fibrillation: diagnosis and management. Evidence review I: Non-ablative rate control therapies. (NICE guidelines; No. NG196). 2021.

Pschyrembel Online. 2022.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

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Created on March 30, 2023

Next planned update: 2026


Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

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