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At 6 months mentax 15mg with visa fungus identification, there was no difference in rate control between digoxin alone and carvedilol alone. The improvement of AF symptoms was greater in patients receiving combined treatment than in patients receiving digoxin alone. The included studies did not allow a direct comparison of these findings with those in other populations. Other subgroups of interest were not specifically evaluated. Strength of Evidence Our review of rate-control drugs explored the comparative effectiveness of beta blockers, calcium channel blockers, digoxin, and other antiarrhythmics in controlling ventricular rate. The 14 included studies varied in terms of the drugs involved, and the lack of multiple studies exploring similar comparisons decreased our ability to quantitatively synthesize their findings. Our findings highlight the lack of definitive data on the superiority of one beta blocker over another or against calcium channel blockers. Our findings underscore the importance of conducting studies comparing the effectiveness, tolerability and safety of different beta blockers and calcium channel blockers and in different patient populations. Based on a limited number of comparative studies, our analysis suggests that either a calcium channel blocker (verapamil or diltiazem) or amiodarone is beneficial compared with digoxin for rate control. Evidence exploring adverse events and safety and effectiveness of the available agents in specific subgroups of interest was insufficient. Table 4 summarizes the strength of evidence for the studied rate-control drugs and outcomes of interest. In general, the limited number of studies exploring specific comparisons, along with the various metrics used to assess outcomes of interest, reduced our confidence in the findings. Strength of evidence domains for rate-control drugs Domains Pertaining to SOE SOE and Number of Magnitude of Outcome Studies Risk of Consistency Directness Precision Effect (Subjects) Bias (95% CI) Beta Blockers vs. Digoxin Ventricular 1 (47) RCT/ NA Direct Imprecise SOE=Insufficient Rate Control Moderate Beta Blockers vs. Calcium Channel Blockers Ventricular 1 (40) RCT/ NA Direct Imprecise SOE=Insufficient Rate Control Moderate Beta Blockers vs. Calcium Channel Blockers in Patients Taking Digoxin Ventricular 1 (29) RCT/ NA Direct Imprecise SOE=Insufficient Rate Control Moderate Exercise 1 (29) RCT/ NA Direct Imprecise SOE=Insufficient Capacity Moderate Quality of Life 1 (29) RCT/ NA Direct Imprecise SOE=Insufficient Moderate Sotalol vs. Metoprolol in Patients Taking Digoxin Ventricular 1 (23) RCT/ NA Direct Imprecise SOE=Insufficient Rate Control Moderate Amiodarone vs. Calcium Channel Blockers Ventricular 3 (271) RCT/Low Inconsistent Direct Imprecise SOE=Low Rate Control Amiodarone is comparable to the calcium channel blocker diltiazem for rate control Amiodarone vs. Digoxin Ventricular 3 (390) RCT/Low Inconsistent Direct Imprecise SOE=Low Rate Control Amiodarone controlled ventricular rate better than digoxin across 2 studies (both p=0. Digoxin Alone Ventricular 1 (52) RCT/ NA Direct Imprecise SOE=Insufficient Rate Control Moderate Calcium Channel Blockers vs. Digoxin Ventricular 4 (422) RCT/Low Consistent Direct Precise SOE=High Rate Control Consistent benefit of verapamil or diltiazem compared with digoxin (p<0. Strict Versus Lenient Rate-Control Strategies KQ 2: What are the comparative safety and effectiveness of a strict rate- control strategy versus a more lenient rate-control strategy in patients with atrial fibrillation? Do the comparative safety and effectiveness of these therapies differ among specific patient subgroups of interest? Key Points • Based on one RCT and one observational study (both good quality) involving 828 patients, there was low strength of evidence to support a decrease in strokes for patients on lenient rate control. This decrease was statistically significant in the RCT, but not in the observational study. Description of Included Studies 17 152,153 Three studies—one RCT and two observational studies representing secondary analyses of RCTs—were included in our analyses. We also included data from a separately 154 17 published subgroup analysis of the one RCT directly included in our analysis (Appendix Table F-2). All studies included outpatients from multiple centers, and all were performed in 17,152 153 Europe. Of the included studies, two were of good quality and one was of fair quality.

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