What are the treatment options for Atrial Fibrillation (Afib) with Rapid Ventricular Response (RVR)?

From the Guidelines

Atrial fibrillation with rapid ventricular response (AFib with RVR) should be managed by first stabilizing the patient and then controlling the heart rate, with a focus on reducing symptoms and improving quality of life, as recommended by the 2024 ESC guidelines 1. For acute management, the following steps should be taken:

• Stabilize the patient and assess their symptoms and medical history
• Control the heart rate using intravenous beta-blockers like metoprolol (5-15 mg IV) or calcium channel blockers such as diltiazem (0.25 mg/kg IV over 2 minutes) as first-line treatments, as suggested by the 2024 ESC guidelines 1
• If the patient is hemodynamically unstable, immediate electrical cardioversion is indicated Once stabilized, oral rate control medications should be initiated, such as:
• Metoprolol 25-100 mg twice daily
• Diltiazem 30-120 mg three to four times daily
• Verapamil 80-120 mg three times daily Anticoagulation therapy should be started based on stroke risk assessment using the CHA₂DS₂-VASc score, typically with direct oral anticoagulants like apixaban 5 mg twice daily or warfarin with a target INR of 2-3, as recommended by the 2024 ESC guidelines 1. For long-term management, consider rhythm control strategies including antiarrhythmic medications (amiodarone, flecainide, propafenone) or catheter ablation for symptomatic patients, with a focus on reducing symptoms and improving quality of life, as suggested by the 2024 ESC guidelines 1. It is also important to note that the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1 provides additional guidance on the management of AFib with RVR, including the use of rate control and rhythm control strategies, as well as the importance of anticoagulation therapy. However, the 2024 ESC guidelines 1 provide the most up-to-date and comprehensive guidance on the management of AFib with RVR, and should be prioritized in clinical decision-making. Key considerations in the management of AFib with RVR include:
• Reducing symptoms and improving quality of life
• Preventing thromboembolism and stroke
• Controlling heart rate and rhythm
• Managing underlying comorbidities and risk factors
• Individualizing treatment based on patient characteristics and preferences.

From the FDA Drug Label

For patients with persistent or paroxysmal AF (PAF) (intermittent AF) at high risk of stroke (i.e., having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, age >75 years, moderately or severely impaired left ventricular systolic function and/or congestive heart failure, history of hypertension, or diabetes mellitus) In patients with persistent AF or PAF, age 65 to 75 years, in the absence of other risk factors, but who are at intermediate risk of stroke, antithrombotic therapy with either oral warfarin or aspirin, 325 mg/day, is recommended.

The management of Atrial Fibrillation (AF) with Rapid Ventricular Response (RVR) involves controlling the ventricular rate and preventing thromboembolic events.

• Rate control can be achieved with medications such as digoxin or beta blockers.
• Anticoagulation with warfarin is recommended for patients with AF at high risk of stroke, as defined by the presence of certain risk factors.
• The target INR range for warfarin therapy in AF patients is 2.0-3.0 2.
• For RVR control, digoxin can be used, with a dose range of 0.25 to 0.75 mg/day, as it slows the ventricular response rate in a linear dose-response fashion 3.

From the Research

Afib with RVR Treatment Options

• Atrial fibrillation (AF) with rapid ventricular response (RVR) is a common dysrhythmia that requires immediate attention to lower the heart rate and prevent further complications 4.
• The primary goal of treatment is to achieve rate control, and several options are available, including calcium channel blockers and β-blockers 4, 5, 6, 7, 8.

Comparison of Diltiazem and Metoprolol

• Studies have compared the efficacy and safety of diltiazem and metoprolol in achieving rate control for AF with RVR 4, 5, 6, 7, 8.
• Diltiazem may achieve rate control faster than metoprolol, but both agents seem safe and effective 4.
• However, diltiazem may be associated with a higher incidence of worsening heart failure symptoms in patients with heart failure with reduced ejection fraction (HFrEF) 5.
• Metoprolol may be associated with a lower risk of adverse events, including hypotension and bradycardia, compared to diltiazem 6.
• An umbrella review of systematic reviews and meta-analyses found that IV diltiazem was more successful in rate control for AF with RVR than IV metoprolol, but also led to a significantly greater reduction in ventricular rate and an increased risk of hypotension 8.

Considerations for Treatment Selection

• Clinicians must consider the individual patient, clinical situation, and comorbidities when selecting a medication for rate control 4.
• Patients with HFrEF may require careful consideration of the potential risks and benefits of diltiazem and metoprolol 5.
• The choice of treatment should be based on the patient's specific needs and medical history, as well as the potential risks and benefits of each medication 4, 5, 6, 7, 8.