Rate versus rhythm: Hi Any views on whether... - AF Association

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Rate versus rhythm


Any views on whether rate or rhythm control is the appropriate treatment for AF or does it depend on the individual or whether its PAF or persistent/permanent?

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I think that most doctors try rate control first, in fact GPs will not normally prescribe rhythm control drugs as only cardiologists seem to do this. If you see a decent cardio or better still an EP then they may well try rhythm control or a combination of both but it is really about reducing symptoms as best for the patient. Only when two separate drugs have failed to control things will ablation come into the equation although many EPs would prefer not to faff about with drugs. Look at CAREAF for best practice.


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I have a very irregular heartbeat unless controlled. My EP said he was not bothered about my fast heart rate; he only wanted to deal with the rhythm. So I'm on drugs that control the rhythm, and now I also don't get my heart going faster sometimes. I don't THINK rate and rhythm are completely separate, they are linked, or can be. I guess, and I stress GUESS, that if your ticker isn't beating properly because the rhythm is, to put it in medical terms, up the spout, then your body may be telling your heart it needs more oxygen, so it beats faster trying to do its job.

Now that's me just saying what I think, no medical knowledge whatsoever.



Rate control did nothing to control either my AF or tachycardia but it made me feel as if I was wading through deep mud. Rhythm control (with a small dose of rate control) now does the job.


Finvola - can I ask what your drug combination is please - Cathy


I'm taking 2 x 100mg Flecainide and 1.5mg Bisoprolol daily, as well as Apixaban.


Thankyou Finovla - I seem to be blighted by any drugs I take BBlockers almost literally brought me to my knees - Calcium C blockers I can only tolerate a low dose at night - tried 50mg Flecanide it made the palpitations I was having at the time much worse - so help what's left for me !!!


Cathy, I feel rather fortunate that Flecainide is working so far. I was taken off Bisoprolol and changed to Sotalol which made my heart race and really scared me about taking anti-arrhythmics.

Jo, I have a friend who was changed to Propafenone from Flecainide and found it worked well. Many people have to keep trying to get the right combination.

Hope you can get a solution Cathy.


Thanks for that - don't know how long I'll have to wait for the results of the 7 day ECG last time it was 6 weeks ! Obviously I would seek help if needed before.


Happyjo - thanks for that Propafenone seems to crop up as being an effective drug but then again so can Flecanide - at present I've got the 7 day monitor attached - they'll have plenty to read from last night and into today - AF full on from 01.00 - 03.00 then slower but still erratic but more comfortable as now - possibly cauliflower cheese for evening meal following a heated disagreement with his lordship!! Need it to settle down as we've got our 3 Grandchildren coming tonight for the weekend wish me luck


What a very interesting question - something I have often wondered about myself.

When I first had fast AF, about 10 years ago, I was cardioverted with Amiodarone (rhythm control). I took this for 7 years plus a diuretic and aspirin. When the AF came back, about 2.5 years ago, Biosoprol was added but reduced the rate very little. Aortic valve surgery followed shortly after. NSR only lasted a few days post-surgery and I was kept on Amiodarone, Bisoprolol and Warfarin until after a DCCV some weeks later. Amiodarone was then withdrawn. When AF returned last spring, I was offered a choice of going back on Amiodarone (still on Bisoprolol) or adding Digoxin. I chose the Digoxin.

My cardiologist's words were that too fast a rate would wear my heart out. Sometimes I feel that my heart beat is irregular, but I am not a good judge, and I get some strong beats, but it is never fast - usually in the 60s. I feel well.

As Koll says, I don't think rate and rhythm are completely separate. My situation may be complicated by having a structurally abnomal heart.


As I understand it rate control drugs work by altering the current flow at the sinus node and decreasing the number of pulses that get down to the ventricles. Rhythm control drugs work by blocking the ion channels that conduct the electricity in the actual heart tissue. Rhythm control drugs can also give some very nasty side effects (esp. amiodarone) and blocking the ion channels can be fatal to patients with some heart problems – which is why they are prescribed by Cardiologists rather than GP’s, and quite often tried out in hospital conditions first.

I have Brugada Syndrome, which is a ‘channel ionopathy,’ and rhythm control drugs would tend to put my heart into VFib. Rhythm control drugs also tend to make atrial flutter worse so can only control it if the flutter is actually set off by AFib in the first place.



Very interesting post, Cyril - thank you for that information.


Hi First bout of PAF back in Oct 2013. EP put me on Flec 50mg twice a day , Biso 2.5mg daily and Apaxiban twice per day. Seems both rhythm and rate control my AF and I only suffer from 1st degree heart block ectopics every few weeks now. Seems we are all different regarding our hearts. Thank fully my heart is structurally fine and no blockages or aneurysms in the coronaries. Will be interesting to hear what the EP has to say on the 20th Jan. Keep you updated.

Keep well


When I first was diagnosed I wanted to go for rhythm control as I felt that would get back to "normal", so I had cardioversions and also Amiodarone to keep there for about 8 years. When I slipped back into AF on 3 occasions during this timeI had another cardioversion to get me back into NSR. But once I had to stop taking Amiodarone and was unable to stay in NSR, I decided to accept that being in permanent AF with just rate control wasn't so bad after all as I don't generally have major symptoms.

So I think it was good to get back into NSR if you can just so I could compare it with being in AF. Then it's a question of how difficult it was going to be to stay in NSR and what problems that would cause versus accepting and living with the AF.

It's not an easy decision, and I think it depends very much on how successful attempts to keep you in NSR will be

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