What is the management of atrial fibrillation (Afib) with rapid ventricular response (RVR) in a patient with heart failure?

From the Guidelines

For managing atrial fibrillation (AFib) with rapid ventricular response (RVR) in a patient with heart failure, beta-blockers and/or digoxin are recommended to control heart rate and reduce symptoms, as stated in the 2024 ESC guidelines 1. The primary goal is to control the heart rate and improve symptoms. Here's a concise management approach:

• Start with intravenous beta-blockers (e.g., metoprolol 5mg IV every 5 minutes, up to 3 doses) or calcium channel blockers (e.g., diltiazem 0.25 mg/kg IV over 2 minutes) for rapid rate control, as recommended by the 2014 AHA/ACC/HRS guideline 1.
• Once stabilized, transition to oral medications:
  • Beta-blockers: metoprolol 25-100mg twice daily or carvedilol 3.125-25mg twice daily
  • If beta-blockers are contraindicated, consider digoxin 0.125-0.25mg daily, as suggested by the 2014 AHA/ACC/HRS guideline 1.
• Target heart rate <110 bpm at rest and <80 bpm during moderate exercise.
• Assess for underlying causes of AFib and heart failure exacerbation (e.g., infection, ischemia, electrolyte imbalances) and address them.
• Consider anticoagulation based on CHA2DS2-VASc score to prevent thromboembolism.
• Optimize heart failure management with ACE inhibitors/ARBs, diuretics, and aldosterone antagonists as appropriate.
• If rate control is inadequate, consider rhythm control strategies such as cardioversion or antiarrhythmic medications under careful monitoring, as recommended by the 2014 AHA/ACC/HRS guideline 1. This approach aims to reduce the rapid heart rate, which can worsen heart failure symptoms by decreasing cardiac output and increasing myocardial oxygen demand. Beta-blockers are preferred in heart failure patients due to their mortality benefit, as stated in the 2024 ESC guidelines 1. Close monitoring of blood pressure, heart rate, and symptoms is essential during treatment.

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 (Afib) with rapid ventricular response (RVR) in a patient with heart failure may involve the use of digoxin to slow the ventricular response rate. The dose of digoxin should be adjusted to achieve a therapeutic effect, with a typical dose range of 0.25 to 0.75 mg/day. 2

• Key points:
  • Digoxin slows rapid ventricular response rate in patients with chronic atrial fibrillation
  • The dose of digoxin should be adjusted to achieve a therapeutic effect
  • Typical dose range: 0.25 to 0.75 mg/day
• Note: The use of digoxin in patients with heart failure and atrial fibrillation should be carefully considered, taking into account the patient's individual clinical circumstances and the potential benefits and risks of treatment. 2

From the Research

Management of Atrial Fibrillation with Rapid Ventricular Response in Heart Failure

The management of atrial fibrillation (Afib) with rapid ventricular response (RVR) in patients with heart failure involves the use of intravenous medications to control heart rate. The following points summarize the key findings:

• Intravenous metoprolol and diltiazem are commonly used to treat Afib with RVR in patients with heart failure 3, 4, 5, 6.
• Diltiazem may be more effective in reducing heart rate and achieving rate control compared to metoprolol 3, 6.
• However, diltiazem may also be associated with a higher incidence of worsening heart failure symptoms 5.
• Beta-blockers, such as metoprolol, are generally recommended for rate control in patients with heart failure, but may have reduced efficacy in patients with Afib 7.
• Digoxin may be used in combination with beta-blockers to achieve rate control, but does not improve survival 7.

Medication Comparison

The following medications have been compared in the management of Afib with RVR in heart failure:

• Metoprolol vs. diltiazem: similar safety outcomes, but diltiazem may be more effective in reducing heart rate 3, 4, 6.
• Metoprolol vs. diltiazem in HFrEF: no difference in total adverse events, but diltiazem may be associated with a higher incidence of worsening heart failure symptoms 5.
• Beta-blockers vs. digoxin: beta-blockers are generally recommended, but digoxin may be used in combination with beta-blockers to achieve rate control 7.

Safety Outcomes

The safety outcomes of medications used to treat Afib with RVR in heart failure include:

• Hypotension: no difference between metoprolol and diltiazem 3, 5, 6.
• Bradycardia: no difference between metoprolol and diltiazem 3, 5, 6.
• Worsening heart failure symptoms: higher incidence with diltiazem compared to metoprolol 5.