The Evidence Regarding the Drugs Used for Ventricular Rate Control

Similarly, the results were not reported stratified by whether the patient had atrial fibrillation or atrial flutter, thus we cannot report the evidence separately for those 2 conditions. We feel this is appropriate, however, because those 2 arrhythmias frequently coexist.^66,67 None of the trials had echocardiographic data as inclusion or exclusion criteria, but that information is more relevant to decisions regarding anticoagulation or cardioversion. We know of no study that associates echocardiographic data with ventricular rate control.

We cannot exclude the presence of publication bias, although we are confident that our search strategy did capture the published literature. In our review of the 8 non–English-language abstracts, we found them in agreement with the articles published in the English literature.

Future research should address the outcomes most relevant to patients — well-being and functionality—particularly since the relationship between heart rate control and exercise tolerance is unclear. We encourage the use of validated instruments for assessment, although which instruments are most appropriate is unknown at this time. Similarly, systematic recording of adverse events should be a regular component of all future trials of these drugs.

Recommendations for clinical practice

For adults with nonpostoperative atrial fibrillation, the evidence supports the following statements. The nondihydropyridine calcium-channel blockers, diltiazem, and verapamil are efficacious for heart rate control at rest and with exercise without decrement in exercise tolerance. Selected b-blockers, such as the noncardioselective b-antagonist nadolol or the second-generation b1-antagonists atenolol and metoprolol, are efficacious at rest and with exercise. There is some evidence, however, that b-blockers cause a transient decrease in exercise tolerance. For patients unlikely to exercise, such as those markedly incapacitated by other illness, digoxin should provide acceptable control.

· Acknowledgments ·

This study was conducted by the Johns Hopkins Evidence-based Practice Center through contract no. 290-97-006 from the Agency for Health Care Policy and Research, Rockville, Maryland. The authors are responsible for its content, including any clinical recommendations. No statement of this article should be construed as an official position of the Agency for Health Care Policy and Research or the US Department of Health and Human Services. We would like to thank Dr Francis Chesley of the Agency for Health Care Policy and Research and Drs Hanan Bell and Michael LeFevre of the American Academy of Family Physicians for their helpful suggestions regarding this project, Dr David Haines of the American College of Cardiology and Drs Ronald Berger and Gary Gerstenblith for their expert advice, Paul Abboud for assistance with data abstraction, and Donna Lea for extensive help with the manuscript.