An IV loading dose followed by maintenance doses of 0.375 to 0.75 mg/day PO divided every 8 to 12 hours is recommended by the American Heart Association as first or second line therapy for supraventricular tachycardia (SVT) with hydrops or ventricular dysfunction, SVT 200 beats per minute or more without hydrops or ventricular dysfunction, or atrial flutter. 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.

This usually means starting diltiazem at a dose of either 120mg once a day or 90mg twice a day. They report fewer symptoms and greater exercise tolerance. Decreased conduction through the AV node reduces retrograde concealed conduction up the accessory pathway, thus increasing antegrade conduction down the accessory pathway.

In patients with sinus rhythm and an ejection fraction of ≤35%, the primary outcome occurred in 134 (29.7%) vs. 150 (33.8%) in the nebivolol vs. placebo group, respectively (HR 0.86, 95% CI 0.68–1.09) and in 61 (24.7%) vs. 73 (31.2%), respectively, if the ejection fraction was > 35% (HR 0.71, 95% CI 0.51–0.99).In this large sample of representative elderly patients with heart failure, we found that the beneficial effect of nebivolol appeared to be attenuated in patients with AF relative to patients with sinus rhythm. Tell your Verapamil reduces renal clearance and hepatic metabolism of digoxin and increases serum levels of digoxin. Further information on duration of AF or on the type of AF (paroxysmal, persistent, or permanent) was known. Although beta-blockers are preferred agents in patients with heart failure and LV systolic dysfunction, low doses of digoxin can be added to therapy with beta-blockers when target heart rate in not achieved with monotherapy, when increased beta-blocker dose is not well tolerated or when the added benefit of increased contractility is needed for heart failure symptom control. However, it should be noted that digoxin may lead to nighttime slowing of ventricular rates, occasionally with long nocturnal pauses, when vagal tone is enhanced and sympathetic tone is low.
The hemodynamic consequences of rapid ventricular rates include a fall in cardiac output, drop in blood pressure, and elevation in left atrial pressure. Call your doctor or get medical Pharmacologic and nonpharmacologic interventions allow care providers to alter the conduction properties of the AV node, thus controlling ventricular rates in AF. In patients with moderate to severe renal insufficiency, a dose of 0.06125 mg daily or 0.125 mg every other day should be used to avoid digoxin toxicity. During sinus rhythm, beta‐blockers exert their heartrate‐lowering effect by targeting the sinus node, whereas during AF their main site of action is the atrioventricular node. Influence of nebivolol on outcome in patients with atrial fibrillation Kaplan–Meier curves for the primary outcome in patients with AF treated with nebivolol vs. placebo are shown in Figure 2 . 2. nondihydropyridine calcium channel blockers (verapamil or diltiazem) In the ATHENA (A Placebo-Controlled, Double-Blind, Parallel Arm Trial to Assess the Efficacy of Dronedarone 400 mg bid for the Prevention of Cardiovascular Hospitalization or Death From Any Cause in Patients With Atrial Fibrillation/Atrial Flutter) trial, dronedarone treatment was associated with a 24% reduction in the combined risk of cardiovascular hospitalization or all-cause death. The bolus of 500 mcg/kg can be repeated up to two more times before every increase in infusion rate. Sustained release diltiazem is given in the same total daily dose as a single tablet or divided twice a day. This is followed by 0.25 mg every 4 to 6 hours until a total of 0.75 to 1.5 mg has been given. Plasma digoxin levels should be monitored periodically to avoid digoxin toxicity in high-risk individuals. In patients with coronary disease after myocardial infarction or with LV systolic dysfunction or heart failure, beta-blockers clearly are preferred. It is important to note that AV nodal ablation has been associated with a small increase in risk of ventricular fibrillation and sudden cardiac death. Such patients usually have underlying AV nodal disease, and rate-controlling medications are generally not advisable as symptomatic bradycardia can ensue.
Therefore one can conclude from these trials that ventricular rate control of AF is an effective and acceptable treatment approach for some patients with AF.