Digoxin is not effective as a sole rate control agent in active, younger patients.Older individuals may benefit from digoxin therapy if they have mild symptoms related to rapid heart rates and are not likely to be physically active. Beta Blocker Heart Meds Might Pose Special Risks for Women Van Gelder, IC, Groenveld, HF, Crijns, HJ. Copyright © 2017, 2013 Decision Support in Medicine, LLC. The data from acute and chronic studies suggest that this approach should continue to be studied and developed.Initial therapy for patients who require chronic rate control during AF should begin with an oral beta-blocker or a nondihydropyridine calcium channel blocker.Beta blockers are preferred in patients with coronary heart disease and heart failure.A nondihydropyridine calcium channel blocker is preferred in patients with reactive airway disease or chronic obstructive pulmonary disease and in patients who do not tolerate beta-blocker therapy.-Addition of digoxin as the second agent when adequate rate control is not achieved with beta-blockers or calcium channel blockers at reasonable doses.When rates are not adequately controlled on a beta-blocker plus digoxin or calcium channel blocker plus digoxin, a third rate-control agent (a beta-blocker in those receiving a calcium channel blocker and vice versa) can be added.In occasional refractory cases, chronic amiodarone or dronedarone therapy for rate control can be considered prior to nonpharmacologic therapies.Some patients will not achieve adequate heart rate control with pharmacologic therapies. Ozcan, C, Jahangir, A, Friedman, PA. “Sudden death after radiofrequency ablation of the atrioventricular node in patients with atrial fibrillation”. It is metabolized by red blood cell esterase within 10 to 20 minutes of administration. “Rate control during atrial fibrillation achieved by chronic endocardial vagal stimulation: proof of principle”. However, the targets and parameters that define optimal rate control in AF have not been well studied or determined adequately. Intravenous amiodarone is generally well tolerated in critically ill patients who develop rapid atrial tachyarrhythmias refractory to conventional treatment and may be less likely to cause systemic hypotension than intravenous calcium channel blockers or beta-blockers.The ACC/AHA/HRS guidelines recommend that intravenous amiodarone be used for heart rate control in patients with AF and heart failure who do not have an accessory pathway (class I indication), and also suggest that intravenous amiodarone can be useful to control the heart rate in patients with AF when other measures are unsuccessful or contraindicated (class IIa indication). In patients with coronary disease after myocardial infarction or with LV systolic dysfunction or heart failure, beta-blockers clearly are preferred.In younger patients who have normal left ventricular function and are more active, calcium channel blockers may be preferable to beta-blockers. Bisoprolol can be taken by adults aged 18 and over. These criteria are similar to the target rates used in the AFFIRM and RACE trials of rate versus rhythm control.The 2011 Focused Update on the Management of Patients with Atrial Fibrillation trial further clarified the issue of optimal rate control in patients with AF by assigning a “strict” rate (<80 bpm at rest or <110 bpm during a 6-minute walk) class III recommendation (no evidence of benefit). Amiodarone should be used with caution in the case of preexcited AF as case reports have described the occurrence of VF after intravenous administration.AFs that should be approached with caution are those presenting with a controlled or slow resting ventricular rate (≤ 60 to 75 bpm) in the absence of any rate controlling medications. The Guidelines for the Management of Patients with Atrial Fibrillation highlight the need for adequate rate control in patients with persistent or permanent AF and they designate measurement of the heart rate at rest and control of the rate with pharmacologic agents as a Class I recommendation.Pharmacologic therapy can achieve adequate rate control in most patients with AF both during acute and long-term management. This allows a therapeutic trial at reduced risk.If an adequate response to initial monotherapy with beta-blockers or calcium channel blockers is not achieved, digoxin can be added as a second agent. Depending on the presentation, therapy initiation can be emergent, urgent, or elective.Mildly symptomatic or asymptomatic stable patients can be treated electively with the addition or increase of oral rate control medications.