Recommendation 1 – Goals of rate control therapy (2010)
We recommend that the goals of ventricular rate control should be to improve symptoms and clinical outcomes which are attributable to excessive ventricular rates (Strong Recommendation, Low Quality Evidence).

Recommendation 2 – Ventricular rate assessment (2010)
We recommend that ventricular rate be assessed at rest in all patients with persistent and permanent AF or AFL (Strong Recommendation, Moderate Quality Evidence).

Recommendation 3 – Heart rate during exercise and exertional symptoms (2010)
We recommend that heart rate during exercise be assessed in patients with persistent or permanent AF or AFL and associated exertional symptoms (Strong Recommendation, Moderate Quality Evidence).

Recommendation 4 – Aim for a resting heart rate of <100 bpm (2010)
We recommend that treatment for rate control of persistent or permanent AF or AFL should aim for a resting heart rate of <100 bpm (Strong Recommendation, High Quality Evidence).

Values and preferences (2010)
Recommendations 3, 4 and 5 place a high value on the randomized clinical trials and other clinical studies demonstrating that ventricular rate control of AF is an effective treatment approach for many patients with AF.

Recommendation 5 – Beta-blockers or nondihydropyridine CCBs as initial therapy (2010)
We recommend beta-blockers or nondihydropyridine calcium channel blockers as initial therapy for rate control of AF or AFL in most patients without a past history of myocardial infarction or left ventricular dysfunction (Strong Recommendation, Moderate Quality Evidence).

Recommendation 6 – Digoxin rate control: selected sedentary and LV systolic dysfunction patients (2010)
We suggest that digoxin not be used as initial therapy for active patients and be reserved for rate control in patients who are sedentary or who have left ventricular systolic dysfunction (Conditional Recommendation, Moderate Quality Evidence).

Recommendation 7 – Digoxin added when other therapies fail (2016, updated from 2010)
We suggest that digoxin can be considered as a therapeutic option to achieve rate-control in patients with AF and symptoms caused by rapid ventricular rates whose response to beta-blockers and/or calcium channel blockers is inadequate, or where such rate-controlling drugs are contraindicated or not tolerated (Conditional Recommendation, Moderate Quality Evidence).

Values and preferences (2016)
Digoxin is considered as a second-line agent in that, although some published cohort, retrospective, and subgroup studies show no harm there are others that suggest possible harm.

Practical tip (2016)
When digoxin is used, dosing should be adjusted according to renal function and potential drug interactions. Given analyses suggesting higher drug concentrations are associated with adverse outcomes, maximum trough digoxin serum concentration of 1.2 ng/mL would be prudent. When digoxin is being used to treat patients with concomitant LV systolic dysfunction, its use should be dictated by the recommendations of the CCS Heart Failure Clinical Guidelines. When digoxin is being used to treat patients with concomitant LV systolic dysfunction, its use should be dictated by the recommendations of the CCS Heart Failure Clinical Guidelines.

Recommendation 8 – Amiodarone for rate control therapy in exceptional cases (2010)
We suggest that amiodarone for rate control should be reserved for exceptional cases in which other means are not feasible or are insufficient (Conditional Recommendation, Low Quality Evidence).

Values and preferences (2010)
Recommendations 6 to 9 recognize that selection of rate-control therapy needs to be individualized on the basis of the presence or absence of underlying structural heart disease, the activity level of the patient, and other individual considerations.

Recommendation 9 – Dronedarone, not for patients with permanent AF (2012)
We recommend that dronedarone not be used in patients with permanent AF nor for the sole purpose of rate control (Strong Recommendation, High Quality Evidence).

Recommendation 10 – Dronedarone, not for patients with history of HF (2012)
We recommend dronedarone not be used in patients with a history of heart failure or a left ventricular ejection fraction <0.40 (Strong Recommendation, Moderate Quality Evidence).

Recommendation 11 – Dronedarone, to be used with caution with patients taking digoxin (2012)
We suggest dronedarone be used with caution in patients taking digoxin (Conditional Recommendation, Moderate Quality Evidence).

Values and preferences (2012)
Recommendations 10-12 recognize that the mechanism(s) for the differences between the results of the ATHENA and the PALLAS trials have not yet been determined. These recommendations are based on the known differences between the 2 patient populations and are also informed by the results of the ANDROMEDA trial.

Recommendation 12 – Beta-blockers as initial therapy in patients with MI or LV systolic dysfunction (2010)
We recommend beta-blockers as initial therapy for rate control of AF or AFL in patients with myocardial infarction or left ventricular systolic dysfunction (Strong Recommendation, High Quality Evidence).

Values and preferences (2010)
This recommendation places a high value on the results of multiple randomized clinical trials reporting the benefit of beta-blockers to improve survival and decrease the risk of recurrent myocardial infarction and prevent new-onset heart failure following myocardial infarction, as well as the adverse effects of calcium channel blockers in the setting of heart failure.

Recommendation 13 – AVN ablation/pacemaker in symptomatic drug-refractory patients (2010)
We recommend AV junction ablation and implantation of a permanent pacemaker in symptomatic patients with uncontrolled ventricular rates during AF despite maximally tolerated combination pharmacologic therapy (Strong Recommendation, Moderate Quality Evidence).

Values and preferences (2010)
This recommendation places a high value on the results of many small randomized trials and one systematic review reporting significant improvements in QOL and functional capacity as well as a decrease in hospitalizations for AF following AV junction ablation in highly symptomatic patients.