Afib Master Class with Dr. Eric Prystowsky — Rate Control

January 20, 2019 

  • Summary: Watch this complimentary Afib Master Class on rate control featuring world-renowned electrophysiologist Eric N. Prystowsky, MD 
  • Reading time: 3 minutes

About This Afib Master Class

This complimentary master class comprises 33 short, information-packed videos in which renowned electrophysiologist Eric N. Prystowsky, MD provides answers to some of the most common questions he hears from afib patients and their families. This is a unique opportunity to hear this information from a doctor’s perspective. This way, you can understand a doctor’s thought process as he or she decides on treatment and leverage that new understanding as you work with your own doctors to make treatment decisions.

The videos are broken up into four main categories, each on its own page: Rate Control (videos below), Rhythm Control (coming soon), Catheter Ablation (coming soon), and Stroke Prevention (coming soon).

You can expect to learn about the difference between rate control and rhythm control, which one (or both) may be right for you, and how to choose the right medications for you. You’ll also discover how to determine whether a procedure is right for you, and if it is, when to have it done. Dr. Prystowsky also discusses the latest research about procedures versus medications to manage afib. Finally, he discusses stroke prevention—including how to work with your doctor or clinician to determine when to consider a stroke prevention device and how to choose between drug options.

If you haven’t done so yet, you may want to watch Expert Advice to Get the Right Treatment for You: How to Work with Your Doctor and Your Insurance to Receive the Medications and Care You Need, the webinar featuring Dr. Prystowsky, which preceded these interviews.

Note: This master class goes into some advanced information, so if you’re new to afib, you may want to check out these other resources first:

About Dr. Prystowsky

At, we consider Dr. Eric N. Prystowsky not only an afib expert, but also an ally and a true advocate for patients. He is now a member of’s Board of Directors and will again be a faculty member at our annual Get in Rhythm. Stay in Rhythm.® Atrial Fibrillation Patient Conference this year.

An electrophysiologist with St. Vincent Medical Group and Director of the Clinical Electrophysiology Laboratory at St. Vincent Indianapolis Hospital, Dr. Prystowsky has co-authored two textbooks, published more than 700 articles, sat on numerous guidelines committees and think tanks, is on the editorial board of 16 journals, and is the Editor-in-Chief of the highly prestigious Journal of Cardiac Electrophysiology. He is the most sought-out afib expert at medical conferences around the globe.

Perhaps more importantly for our purposes, Dr. Prystowsky has played an important role in getting the afib patient community a seat at the table with our doctors, which means that the people who make decisions about our care are able to consider our concerns, wants, needs, and desires. In addition to inviting afib patients to speak at medical conferences so doctors and nurses would understand the patient perspective, he also brought patients into think tanks and advisory boards, so the professionals caring for us could ensure treatment is more patient-focused.

Afib Master Class with Dr. Eric Prystowsky — Rate Control

Discover a doctor’s perspective on the difference between rate control and rhythm control, which one (or both) may be right for you, and how to work with your doctor(s) to choose the right medications for you. You’ll also learn why it’s important to discuss these options as early during your treatment as possible, and which possible side effects to anticipate as you use rate control. 

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Note:  These videos contain Closed Captioning. On a computer, you can access Closed Captioning by clicking on the CC icon on the bottom right of the video until you see a red line under the CC icon. On a mobile device, ways to access Closed Captioning may vary. 

What Are Rate Control and Rhythm Control?

[00:09] Rate control and rhythm control are two different treatment options.

[00:14] For rate control, the issue is keeping somebody who’s in afib with a tolerable ventricular rate. The top chambers are always fast, like 400 plus beats a minute, and what gets through the conduction system to the bottom is what the patient feels or what’s on the ECG. So, rate control means controlling the rate to a reasonable amount. Let’s say, a mean during the day of 80 beats a minute.

[00:39] Rhythm control, on the other hand, is the process of restoring and maintaining normal rhythm.

[00:45] So, rhythm control means a process of maintaining the normal sinus rhythm. Rate control is the process of allowing afib to be there, but keeping the heart rate down.

How Do You Decide on Rate Control, Rhythm Control, or Both?

[00:09] One of the most frequent problems and questions that come up in patient discussions with afib is which treatment strategy do you select?

[00:18] Do you look at rate control philosophy, or do you look at rhythm control? Remember, they’re not always exclusive of each other. There are a lot of patients who, when they slip back into atrial fib, still need rate control.

[00:32] So, you have to sit down with each patient, and you have to find out what their symptoms are, how frequently is their atrial fibrillation, what are the chances that you have of being able to maintain and restore sinus rhythm, and at what cost? Ablation? Drugs that may have side effects?

[00:49] So, these are very individual decisions, but the critical thing is to make sure you discuss these early in the therapy, because if you allow someone to stay in atrial fib for long periods of time — I don’t mean weeks, I mean months and years — you may lose the advantage of trying to get rhythm control.

What Are the Types of Rate Control Drugs?

[00:10] If you’re going to select a rate control treatment strategy, you have several drugs to choose from, and they are in certain classes. For example, beta blockers.

[00:22] In the class of beta blockers, there’s lots of choices you could look at. You could look at a drug like propranolol, atenolol, metoprolol, nadolol — there are just many of them — carvedilol. And, whatever suits you best and the patient best. There’s not a ton of differences in my own experience. What I do try to do is to move a patient to a long-acting beta blocker, if at all possible. It’s easier for the patient to take.

[00:47] The other class of drugs, which for me in many cases are actually more effective, are what’s called the slow channel blockers. They work by a different mechanism, but they also control the heart rate during afib. Those are really two drugs: verapamil and diltiazem. I sometimes start at lower doses, and when I find the right dose of those drugs, I will give again a long-acting preparation.

[01:11] And third is digitalis, but I would like to warn you not to use digitalis unless you absolutely have to. There are data in the literature that suggest that digitalis, in large groups of patients, can increase mortality. So, if it must be used because there are no alternatives, then you have to use it, but I hardly ever have a patient taking digitalis.

[01:33] Last of all, the concept that you have to use high doses of a drug to get control belies the fact that you can get away with less side effects, and it’s good rate control, by using more than one drug. So, sometimes I’ll use a small dose of a beta blocker and a dose of a slow channel blocker, like verapamil or diltiazem, get excellent rhythm control without engaging the side effects that occur with high doses of both drugs.

What Are the Side Effects From Rate Control Drugs or Poor Rate Control?

[00:09] Side effects can occur with rate control. And, they occur with the drugs or with poor rate control, or actually poor rate control either too slow or too fast. So let’s go through those.

[00:20] First of all, the drugs. Beta blockers are well tolerated by a lot of people. They’re not well tolerated by younger people very well, and they often can cause, you know, what some people call the beta blocker blues — a foggy sensation, just not feeling well. So, you have to figure that out. Not everybody’s a good candidate for a beta blocker.

[00:43] The slow channel blockers are better tolerated in that regard, but they can cause some constipation, some ankle swelling. And, I’ve had some women patients who when they get the ankle swelling, they’re done. I mean, they don’t want it. And, I understand, it’s a cosmetic thing, so you have to kind of pick and choose.

[01:00] So, those are the complications of the drugs, but there’s also complications of inappropriate rate control. Number one, too slow a rate. So, you gave too much drugs. Okay. And, now the patient is sluggish because their heart rate during the day is 50 or 60 and they can’t get a rate up high enough during exercise and then you have to peel back the drugs.

[01:21] Or a worse situation, in my opinion, is inadequate rate control from too fast. If you have fast heart rates for long periods of time, you can develop a cardiomyopathy and heart failure. And, the hallmarks of that, in my experience, are the patient who really doesn’t feel their atrial fibrillation. They don’t know they’re in it and they’re blitzing along at 120, 30, 40 a minute all the time. And, they come in with things like shortness of breath because they slip into heart failure.

[01:50] So, the drugs have side effects, and inappropriate rate control has side effects, and you just have to figure out the right combination for that patient.

How Can You Prevent Heart Failure in Patients on Rate Control?

[00:10] When one picks a rate control philosophy or strategy, what I discuss in the office with my patients is the following: the most important thing here is to prevent heart failure.

[00:22] I must know that whatever therapy I’m giving you is controlling your rate, not overdoing it, but is controlling your rate, to the point that your heart rates aren’t running rapid all day long because I want to avoid a situation of decreased heart pumping and heart failure. It’s a condition called tachycardia-mediated cardiomyopathy. If caught early enough, in my experience, it’s almost always reversible.

[00:48] I’m currently putting together a series. We have almost 50 patients with this, and they are absolutely the same kind of patients. They come in not knowing they’re in afib; it’s picked up on an exam at a doctor’s office, or they have shortness of breath. And, you can usually turn this around. So, the critical thing is to make sure you’re controlling it.

[01:08] So, it’s not good enough to send the patient home with, here’s your 50 milligrams of metoprolol a day. Not good enough. It is up to you, as a physician, to be sure that you get a follow-up Holter monitor, whatever you want to do, to see that their rate’s truly controlled. That is a cardinal thing that must be done.

[01:28] So, you can’t just give a drug; you have to give a drug and see if it’s working.

When Do You Consider Changing Someone From Rate Control?

[00:10] Often patients will come to me with rate control treatment, and maybe the doctor didn’t know any other treatment options. Maybe they didn’t tell the patient, “Hey, by the way, I could do something more sophisticated,” or “Maybe if I send you to someone…”

[00:24] So, they come to me with actually good drugs, good rate control, but they’ve been in persistent atrial fib. And, then you start to dig a little bit, and you say, “Well, how’re you feeling?” “Well, I don’t feel those palpitations, doc.” I say, “Well, that’s not the only symptom of afib. How’s your energy level?” “Well, not so good lately.”

[00:43] And then you start to peel back the onion, and you find out actually this all started with the atrial fib. All these subtle signs, okay, of atrial fib. So, this is why you must discuss treatment options with the patient upfront. Patients need to understand that. They need to know what their options are.

[01:00] So, if a patient has been in persistent atrial fib and is really not feeling that well, or has a question of are there other options, they should seek out an electrophysiologist and discuss the other options because the other options clearly are either a medicine or an ablation procedure to maintain sinus rhythm.

When Is It Time to Change From Rate Control to Rhythm Control?

[00:10] An unfortunately not uncommon consultation to me is a patient who comes with atrial fib. Now, they may be reading something, and they heard something about, “Hey, this afib isn’t the best thing in the world. I need to check it out.” Or, they may actually have some symptoms and are finally saying maybe I ought to see someone else. Or, they had a friend of theirs — these are often what happens — “You have afib? My God, you need to see your doctor.” One of those sort of moments.

[00:40] Here’s the thing, even if your rate’s under good control, the natural history of staying in afib is the concept of “afib begets afib.” The myocardial cells in the top chamber, the atrial cells, will tend to die out. You will get fibrosis, some scarring in the top chambers. They tend to dilate up, and you get to a point of no return if you wait too long.

[01:03] And you might say, “Well, who cares? Right? I mean, I feel fine, and I’m on a blood thinner, so who cares?” Well, you should care, because there are more recent data suggesting that patients in atrial fib, even though all those boxes are checked, may have other things.

[01:20] Now they aren’t hardcore data, but they are disturbing data. There are data from multiple sources saying there’s an increase in cognitive dysfunction. So, brain things. People find these silent ischemic, you know, infarcts in the brain. There are all these little things that are starting to build up with multiple studies. There isn’t like that one aha moment major study that’s clearly nailed this, but there are a lot of studies out there all going in the wrong direction.

[01:49] So, I’m not saying that you must be in sinus rhythm. All I’m saying is there are a number of studies that have shown you can have decreased heart function, even with good rate control.

[01:58] That’s one of the things we missed years ago, or certainly I did. The clinical saw was if you have decreased heart function due to atrial fib, it’s because your rate was too high. Yeah, that’s true. But, there were early signs a couple of decades ago that if you ablated these patients and restored sinus rhythm, their heart pumping function went up, called an ejection fraction, their squeezing ability went up.

[02:21] And I remember reading that and thinking, “wow, that’s kind of interesting.” And, then I saw another article saying the same thing.

[02:28] I’ve had my own patients who’ve had decreased heart function but are doing very well, and suddenly they’ll call, they’re short of breath. Their rate is well controlled. They’ve slipped back into atrial fib. Some patients simply need sinus rhythm to have adequate cardiac output.

[02:46] So, all these factors have to be taken into account before any patient is allowed to be in permanent atrial fib. You really have to understand there are downsides to that. And, if you wait too long, you may be at the point of no return.

[02:59] So, it’s not just your rate is controlled and you’re okay now. What about five years from now? Okay, it’s like playing chess. It’s not just your first move; it’s thinking six moves ahead. Atrial fib is a years and years disease, and you’ve got to think forward.

Does Being Only On Rate Control Predispose You to a Stroke?

[00:09] One of the major unanswered questions, and it’s one that I’ll be honest has plagued me for decades, is “Does rate control – in other words, let someone stay in afib – predispose one to stroke if (now remember importantly) if you’re adequately anticoagulated?”

[00:25] So, I’d like to discuss this in a little more detail because first of all the answer isn’t in, but there are a lot of intriguing data out there. It really, in many ways, depends on if you’re prone to a stroke.

[00:37] Let me give you an example. You could take a person in their forties who has persistent atrial fib, and for whatever reason, someone’s allowed them to stay in it, and they have no risk factors for stroke. They probably won’t get a stroke. And, then you could take somebody maybe in their seventies who has hypertension, diabetes, etc., etc., and they can be in afib for a short period of time and may wind up with a stroke.

[01:00] So, you have to look at this as, “What role does atrial fib play, and there’s no question atrial fib plays a role, and what role are the endothelial factors in the atrium playing?” And, it’s complex.

[01:12] So, if you have somebody that stays in afib for a long period of time, there are pretty good data now showing you change the architecture, the endocardium, the inner lining of the top chamber, and make it more prone to a thrombus.

[01:28] So, the obvious next step would be to say, “well, if I restore and maintain sinus rhythm, I’m out of the doghouse; I mean, I don’t have to worry about strokes now.” I wish that were the case, and it may be the case, but it’s not proved yet.

[01:43] So, I’m not willing, at this point in time, to say categorically that that’s true. But, I have to tell you my gut, for whatever that’s worth and probably not much when you’re worried about stroke, says that there probably is some truth to the fact that if we can maintain sinus, you are less likely to have a stroke. But, you need to know, there are no data to support that at this time and I think that’s an area of active, ongoing research.

What Next?

To watch the other videos in this master class, follow the links below:

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