Rythm control vs rate control

Rythm control vs rate control

Another day another question :)

I am confused as my AF symptoms are far more about a frankly demented rythm than a speeding HR.  I have a lowish resting rate at around 55 and it doesn't seem to go up appreciably during an attack.   I am therefore wondering rythm control will be more effective than rate control.  

I know HR control is the first port of call but I wondered if anyone else has found that their rythm is the problem more than their HR and have been medicated accordingly ?

Thanks all 

12 Replies

  • Dear Ahab, I have AF but it turns out that I have a low ventricular rate because I have a rare condition where there are patches of disease in the Bundle Of His (infrahisian disease).  This, I understand, means the ventricles do not beat rapidly. The only medication I am on is Rivaroxaban.  I feel it is now time to try and find out more about my condition and what potential options for treatment may be? At the moment my consultant is monitoring my condition and for the most part I lead an active life although I have slowed down a lot! Wishing you all the best.

  • Yes, I do not have a rate problem. Rhythm is all over the place during an episode. 

    Various cardiologists tried me on atenolol, Amiodarone, Soltalol then bisoprolol. I then saw an EP who prescribed flecainide.

  • I think you need to see an EP pretty soon. Not everybody gets on with beta blockers  but rate control is always the first port of call. GPs will not generally prescribe rhythm control drugs.

  • I'm seeing the cardiologist )who first diagnosed it) next week.   He's not an EP so I will ask about that.  I understand his inteniton is to start the ball rolling ref meds then let the GP take over.  I have a great GP so I feel confident I can ask her for an EP referral if the cardiologist isn't helpful (not that I anticipate a problem ). Ps sorry about the weird huge sideways photo I'm my post - I was just trying to add a tiny avatar one and that appeared with no way to delete 😨. 

  • Hard to tell about the referral. Some give it easily and others are totally against EPs.

    Quite a few of the heart related drugs have to be prescribed in the first instance by a cardiologist or EP. Then GPs can repeat and make some dose adjustments.

    Worth remembering that EPs are cardiologists who have specialised in arithmyias.

    If your chosen EP is not in the same CCG then make sure you get copies of all your tests, etc so that your history can be built up.  I have always asked for copies of all test results including bloods, ECGs, etc and all hospitals and GP have given them without any problem.

    Good luck next week.

  • Rhythm control drugs are pretty horrible. I was on amiodorone for 3 months and it's side effects were horrible, and some of them are still with me 2.5 months after stopping.

    Make sure you research the side effects before committing

  • Oh , push for an EP referral, they know about AF

  • The way it was explained to me when I was first diagnosed, is that when in AF your heart is beating about 3 times faster on the inside than the measured heart rate. And this is why they want your heart rate kept down. Although a resting HR of 55 is really good, I guess they want to make sure it doesn't go up to high. 

    I'm a bit different because my AF is caused by an over active thyroid so there is no point them trying rhythm control with me until my thyroid is under control. My hormones are telling my heart to beat faster and the meds I'm on try to keep it down. I sit at anywhere from 50-100 but it's really impossible to know exactly even in AF all the time.

    Anyway as others say an EP referral would be a good idea if you can get one. 

    Good luck

  • Agree with all the comments about seeking advice from a specialist, but I can confirm that with a resting heart rate around 55, which is similar to me, then it could be potentially helpful to you to have ryhthm control medication. The only thing is that for some people rhythm control meds can be pro Arrthymic i.e. they can bring on AF as well as help to control it! That is why rhythm control medication is often prescribed with a small dose of beta blocker; all the more reason why you should get specialist advice. 

  • With low heart rate Flecanaide can push it lower in some circumstances although its not supposed to so they may be reluctant to go there.

  • It seems to me that rate control used alone is an acceptance of defeat. The first priority ought to be getting the heart back into NSR with a rhythm control drug, not to leave the arrhythmia running and just limit the rate. I take both, but the rate control is only a safety backup in case the rhythm control fails.

    Mikee, Amiodarone is regarded as a drug of last resort because of the dangerous side effects,  according to the ESC "flecainide is now recommended as one of the first-line treatment options for restoring and maintaining SR in patients with AF under current treatment guidelines".

  • My EP approved my taking anticoagulant (Pradaxa) & rate control drug (Verapimil) & forgo the they the control drug (Flecainide), as long as I don't have an extended AF event.  I don't think I have, only some ectopic beats, but I have ordered an Alivecor to make sure.  As I stated I another post, Pradaxa & Verapimil can't be taken at the same time, & both need to be taken twice a day, so scheduling is difficult.  When reversal agents are available for the other NOACs I will consider switching.  Or, if I stop worrying so much about a reversal agent. 

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