Permanent Atrial Fibrillation When Combination Rate Control Has Not Achieved the Target Heart Rate

Clinical scenario

Permanent atrial fibrillation — AF for which no further attempts at restoration of sinus rhythm are planned, following a shared decision between the patient and physician. The focus is sustained heart rate control.

Prior line — escalation trigger

The previous step used combination rate control therapy (avoiding bradycardia). Despite this, the target of a resting heart rate below 110 b.p.m. was not achieved, or symptoms continued despite lenient control. This protocol defines what to do next.

Next-line approach — partial overview

Management at this stage involves intensifying rate control under observation. In patients who remain unresponsive, a procedural intervention targeting the atrioventricular node may be evaluated. The full patient selection criteria, sequencing, and monitoring requirements are contained in the structured protocol.

Treatment target —

Resting heart rate <110 b.p.m.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1093/eurheartj/ehae176

AF for which no further attempts at restoration of sinus rhythm are planned, after a shared decision between the patient and physician.
Atrioventricular node ablation in combination with pacemaker implantation should be considered in patients unresponsive to, or ineligible for, intensive rate and rhythm control therapy to control heart rate and reduce symptoms.
Lenient rate control with a resting heart rate of < 110 b.p.m. should be considered as the initial target for patients with AF, with stricter control reserved for those with continuing AF-related symptoms.

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