What is the management of atrial fibrillation (AF) with rapid ventricular response (RVR) in patients with normal blood pressure (normotension)?

From the Guidelines

For managing atrial fibrillation with rapid ventricular response (AF with RVR) in normotensive patients, the primary goal is to control the ventricular rate while maintaining hemodynamic stability, and initial treatment should focus on rate control with intravenous beta-blockers such as metoprolol or diltiazem, as recommended by the 2024 ESC guidelines 1. The choice of initial treatment depends on various factors, including the presence of underlying heart disease, left ventricular function, and symptoms.

• Beta-blockers, such as metoprolol (5-15 mg IV in divided doses), are effective in controlling heart rate and reducing symptoms in patients with AF and left ventricular ejection fraction (LVEF) >40% 1.
• Diltiazem (0.25 mg/kg IV over 2 minutes, followed by infusion if needed) is another option for rate control, especially in patients with HFpEF 1.
• Verapamil (80-120 mg three times daily) can also be used for rate control, but its use may be limited by its negative inotropic effect in patients with reduced LVEF 1.
• Digoxin (0.5 mg IV loading dose, followed by 0.25 mg IV every 6 hours up to 1.5 mg total, then 0.125-0.25 mg daily orally) may be considered in patients with reduced ejection fraction, but its use is generally limited to patients with severe symptoms or those who cannot tolerate other rate-control medications 1. Anticoagulation should be initiated based on the CHA₂DS₂-VASc score to prevent thromboembolism, as recommended by the 2014 AHA/ACC/HRS guideline 1. For patients with persistent symptoms or difficulty achieving rate control, rhythm control with antiarrhythmic drugs like amiodarone or electrical cardioversion may be considered, but the choice between rate and rhythm control strategies depends on symptom severity, duration of AF, comorbidities, and patient preferences 1. Long-term management should include addressing underlying causes such as hypertension, sleep apnea, or thyroid disease, and atrioventricular node ablation combined with cardiac resynchronization therapy may be considered in severely symptomatic patients with permanent AF and at least one hospitalization for heart failure 1.

From the FDA Drug Label

In patients with chronic atrial fibrillation, digoxin slows rapid ventricular response rate in a linear dose-response fashion from 0.25 to 0. 75 mg/day.

The management of atrial fibrillation with rapid ventricular response in normotensive patients can be achieved with digoxin, which slows the ventricular response rate in a dose-dependent manner.

• The dose of digoxin for this purpose ranges from 0.25 to 0.75 mg/day.
• However, it is essential to note that digoxin should be used with caution, especially in patients with certain conditions, such as heart failure or electrolyte imbalances.
• Additionally, verapamil can also be used to control ventricular rate in patients with atrial fibrillation, but its use may be limited in patients with severe left ventricular dysfunction or concomitant beta-blocker therapy 2, 3, 4.

From the Research

Management Strategies

• The management of atrial fibrillation (AF) with rapid ventricular response (RVR) in normotensive patients involves controlling the ventricular rate, with intravenous (i.v.) beta blockers and calcium channel blockers being equally effective in selected individuals 5.
• The addition of digoxin to the regimen can cause a favorable outcome, but digoxin as a single agent is generally inefficacious in slowing the ventricular rate in acute AF 5.
• In patients with heart failure (HF), diltiazem is not recommended due to negative inotropic effects, but studies have shown similar safety and effectiveness outcomes between i.v. metoprolol and diltiazem in HF patients with concomitant AF with RVR 6.

Comparative Effectiveness of Medications

• A study comparing metoprolol, diltiazem, and amiodarone in the management of AF with RVR in the intensive care unit (ICU) found that metoprolol had a lower failure rate than amiodarone and was superior to diltiazem in achieving rate control at 4 hours 7.
• Another study found that i.v. diltiazem reduced heart rate more quickly and reduced heart rate by 20% or greater more frequently than i.v. metoprolol in patients with AF with RVR and HF, with no safety outcome differences 6.
• A systematic review and meta-analysis found that metoprolol was associated with a 26% lower risk of adverse events compared to diltiazem in patients with AF with RVR, with no difference in rates of bradycardia or hypotension 8.

Adverse Effects

• A study found that the incidence of adverse effects, including hypotension and bradycardia, was similar between diltiazem and metoprolol in patients with heart failure with reduced ejection fraction (HFrEF) and AF with RVR, but the diltiazem group had a higher incidence of worsening heart failure symptoms 9.
• Another study found that patients with higher initial heart rates faced higher rates of adverse events, and that metoprolol had lower rates of adverse events compared to diltiazem in patients with AF with RVR 8.