Table 1.

Therapeutic options for rate and rhythm control of atrial fibrillation.

Therapy	Rhythm	Rate	Comments
Beta-blockers		✓	Often first line, good safety profile. Caution in asthma and acute heart failure.
Non-DHP calcium-channel blockers		✓	Contraindicated in HFrEF.
Digoxin		✓	Narrow therapeutic range—monitor serum levels.
Class I AADs	✓		Monitor QRS (class IC) or QT-interval (class IA). Contraindicated in HFrEF. Consider pill-in-the-pocket approach in selected patients.
Class III AADs	✓	✓	Avoid in long-term due to potentially toxic side effects, especially for amiodarone. Useful for pre-treatment of DCCV. Monitor QT interval.
Cardioversion	✓		Generally safe. Consider in persistent AF to assess symptom status in sinus rhythm and guide further management.
Catheter ablation	✓		The most effective rhythm control approach. Especially beneficial in heart failure/tachycardiomyopathy. Note upfront procedural risks. Patient preference is very important.
Pace & ablate		✓	Generally last line therapy, but essentially guarantees rate control and ventricular regularity. Renders patient dependent upon pacemaker—hence ideally avoid in younger patients due to infection risk with repeated box changes.

AAD, anti-arrhythmic drug; AF, atrial fibrillation; DCCV, direct current cardioversion; DHP, dihydropyridine; HFrEF, heart failure with reduced ejection fraction.