See section 1.8 for rate and rhythm control for people presenting acutely (either new onset or destabilisation of existing atrial fibrillation). Rate control 1.7.1 Offer rate control as the first-line treatment strategy for atrial fibrillation except in people: whose atrial fibrillation has a reversible cause who have heart failure thought to be primarily caused by atrial fibrillation with new-onset atrial fibrillation with atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm for whom a rhythm-control strategy would be more suitable based on clinical 1.7.2 Offer either a standard beta-blocker (that is, a beta-blocker other than sotalol) or a rate-limiting calcium-channel blocker (diltiazem or verapamil) as initial rate-control monotherapy to people with atrial fibrillation unless the person has the features described in recommendation 1.7.4. Base the choice of drug on the person's symptoms, heart rate, comorbidities and preferences. [2021] In April 2021, this was an off-label use of diltiazem. See NICE's information on prescribing medicines. 1.7.3 For people with atrial fibrillation and concomitant heart failure, follow the recommendations on the use of beta-blockers and avoiding calcium- channel blockers in NICE's guideline on chronic heart failure. [2021] 1.7.4 Consider digoxin monotherapy for initial rate control for people with non-paroxysmal atrial fibrillation 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. [2021] 1.7.5 If monotherapy does not control the person's symptoms, and if continuing symptoms are thought to be caused by poor ventricular rate control, consider combination therapy with any 2 of the following: a beta-blocker diltiazem digoxin. [2021] In April 2021, this was an off-label use of diltiazem. See NICE's information on prescribing medicines. 1.7.6 Do not offer amiodarone for long-term rate control. 