Other drugs used to control the ventricular rate in AF

Digoix may also be used in the control of ventricular rate in atrial fibrillation:

• beta-blockers:
  • may be used alone or in conjunction with digoxin
  • reduce ventricular rate at all levels of exercise
  • do not increase exercise capacity
    
    
• verapamil and diltiazem:
  • reduce ventricular rate at rest and during exercise
  • improve exercise capacity in 7-8% of patients with AF
  • verapamil may be combined with digoxin

NICE suggest:

• offer either a standard beta-blocker (that is, a beta-blocker other than sotalol) or a rate-limiting calcium-channel blocker as initial monotherapy to people with atrial fibrillation who need drug treatment as part of a rate control strategy. Base the choice of drug on the person's symptoms, heart rate, comorbidities and preferences when considering drug treatment
  
  
• digoxin should only be considered as monotherapy if
  • the person does no or very little physical exercise or
  • other rate-limiting drug options are ruled out because of comorbidities or the person's preferences
    
    
• if monotherapy does not control symptoms, and if continuing symptoms are thought to be due to poor ventricular rate control, consider combination therapy with any 2 of the following:
  • a beta-blocker
  • diltiazem
  • digoxin
    
    
• do not offer amiodarone for long-term rate control

Reference:

• NICE (April 2021). Atrial fibrillation: the management of atrial fibrillation