Does atrial fibrillation (AFib) with rapid ventricular response (RVR) require hospital admission?

From the Guidelines

Atrial fibrillation with rapid ventricular response (AFib with RVR) does not always require hospital admission, and the decision should be based on individual patient factors, including hemodynamic stability, symptoms, and access to prompt outpatient follow-up, as recommended by the most recent guidelines 1. The management of AFib with RVR involves rate control, prevention of thromboembolism, and correction of the rhythm disturbance, with the initial management decision involving primarily a rate-control or rhythm-control strategy 1.

• Key factors to consider in the decision to admit or discharge a patient with AFib with RVR include:
  • Hemodynamic stability
  • Severity and type of symptoms
  • Associated cardiovascular disease
  • Patient age
  • Associated medical conditions
  • Access to prompt outpatient follow-up According to the 2024 ESC guidelines for the management of atrial fibrillation 1, rate control therapy is recommended in patients with AF, and beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs to control heart rate and reduce symptoms.
• The guidelines also suggest that atrioventricular node ablation combined with cardiac resynchronization therapy should be considered in severely symptomatic patients with permanent AF and at least one hospitalization for HF to reduce symptoms, physical limitations, recurrent HF hospitalization, and mortality 1. In general, patients who are hemodynamically unstable or have severe symptoms should be admitted for immediate management, while stable patients with adequate rate control and reliable follow-up may be discharged with oral rate control medications and close outpatient monitoring 1.

From the Research

Hospital Admission for Afib with RVR

• Afib with rapid ventricular response (RVR) is a common tachyarrhythmia that often requires hospitalization due to increased morbidity and mortality from hemodynamic consequences 2.
• The decision to admit a patient with Afib and RVR to the hospital depends on various factors, including hemodynamic stability, cardiovascular status, and associated noncardiac clinical disorders 2, 3.

Management Strategies

• Intravenous beta blockers and calcium channel blockers are effective in controlling the ventricular rate in acute Afib, while digoxin can be added to the regimen for a favorable outcome 2.
• In cases of ventricular preexcitation syndrome associated with rapid ventricular rate due to Afib, intravenous procainamide is the drug of choice 2.
• Emergent cardioversion is indicated in hemodynamically unstable patients, while rate or rhythm control should be pursued in hemodynamically stable patients 3.

Disposition and Risk Assessment

• Disposition can be challenging, and several risk assessment tools (e.g., RED-AF, AFFORD, and the AFTER scores) are available to assist with disposition decisions 3.
• Understanding recent updates in the literature concerning Afib with RVR can help emergency clinicians make informed decisions about patient care 3.

Comparative Effectiveness of Management Options

• Metoprolol has been shown to have a lower failure rate than amiodarone and is superior to diltiazem in achieving rate control at 4 hours in patients with Afib and RVR 4.
• The use of anticoagulants, rate-controlling drugs, and antiarrhythmic drugs in patients with Afib has been explored, with warfarin being mentioned in an average of 37% of all Afib-related visits 5.