A 58-year-old man with hypertension and left ventricular hypertrophy presents with newly diagnosed atrial fibrillation with a ventricular rate of 110 bpm. Echocardiography shows normal left ventricular ejection fraction (LVEF 50%). He has no structural heart disease or contraindications to rate control. What is the drug of choice for rate control in this patient?

Explanation

## Rate Control in AF with Preserved LVEF **Key Point:** Beta-blockers are first-line agents for rate control in atrial fibrillation, particularly in patients with hypertension and left ventricular hypertrophy. ### Rationale for Beta-Blockers 1. **Dual benefit**: Reduce heart rate AND lower blood pressure, addressing both AF and underlying hypertension 2. **LVH regression**: Beta-blockers promote regression of left ventricular hypertrophy over time 3. **Cardioprotective**: Reduce myocardial oxygen demand and provide ischemic protection 4. **Evidence-based**: Guideline-recommended first-line agent for rate control in AF with preserved LVEF ### Comparison of Rate-Control Agents | Agent | First-Line | Mechanism | Key Advantage | Key Limitation | |-------|-----------|-----------|---------------|----------------| | **Beta-blockers** (metoprolol, atenolol) | Yes | AV node blockade | Hypertension control, LVH regression | Contraindicated in decompensated HF, asthma | | **Non-dihydropyridine CCBs** (verapamil, diltiazem) | Yes (alternative) | AV node blockade | Effective rate control | Negative inotrope, avoid in HFrEF | | **Digoxin** | No (second-line) | Vagomimetic + AV block | Useful in sedentary patients, HFrEF | Narrow therapeutic index, less effective with sympathetic activation | | **Amiodarone** | No (rhythm control) | Class III antiarrhythmic | Rhythm + rate control | Toxicity risk, reserved for refractory cases | **High-Yield:** In AF with hypertension and LVH, beta-blockers are preferred because they address the underlying hypertension while controlling ventricular rate — a synergistic benefit not offered by digoxin or verapamil alone. **Clinical Pearl:** Metoprolol (or atenolol) is preferred over verapamil in this patient because the presence of LVH suggests a hypertensive substrate; beta-blockers provide superior blood pressure control and promote LVH regression, whereas verapamil does not. **Tip:** In NEET PG, when you see "AF + hypertension + LVH," think **beta-blocker first**. Verapamil or diltiazem are alternatives if beta-blockers are contraindicated (asthma, severe bradycardia, decompensated HF).