From the Guidelines
The treatment for a patient with congestive heart failure (CHF) and atrial flutter with rapid ventricular response (RVR) should focus on rate control, rhythm control, and addressing the underlying heart failure, with initial rate control achieved using intravenous beta-blockers or calcium channel blockers, as recommended by the 2019 ACC/AHA guidelines 1. The goal of treatment is to improve morbidity, mortality, and quality of life by controlling the ventricular rate, preventing thromboembolic events, and managing symptoms.
- Rate control can be achieved using intravenous beta-blockers, such as metoprolol 5mg IV every 5 minutes, up to 3 doses, or calcium channel blockers, such as diltiazem 0.25 mg/kg IV over 2 minutes, followed by infusion if needed.
- For patients with decompensated heart failure, amiodarone (150mg IV over 10 minutes, followed by 1mg/min for 6 hours) may be preferred as it has less negative inotropic effect, as suggested by the 2014 AHA/ACC/HRS guidelines 1.
- Once stabilized, anticoagulation should be initiated based on CHA₂DS₂-VASc score, typically with heparin initially, transitioning to warfarin or a direct oral anticoagulant.
- Rhythm control strategies include electrical cardioversion (synchronized at 50-100J) for hemodynamically unstable patients or chemical cardioversion with amiodarone.
- Long-term management includes optimizing CHF therapy with ACE inhibitors/ARBs, beta-blockers, diuretics, and aldosterone antagonists.
- Catheter ablation may be considered for recurrent atrial flutter, as suggested by the 2019 ACC/AHA guidelines 1. The dual approach of treating both the arrhythmia and heart failure is essential because the rapid heart rate can worsen heart failure by reducing diastolic filling time and cardiac output, while heart failure creates structural changes that perpetuate arrhythmias.
From the Research
Treatment for Patient with CHF and Atrial Flutter in RVR
- The treatment for a patient with congestive heart failure (CHF) and atrial flutter in rapid ventricular response (RVR) typically involves acute heart rate control using intravenous (IV) non-dihydropyridine calcium channel blockers (CCB) or beta blockers (BB) 2, 3.
- For patients with concomitant heart failure with reduced ejection fraction (HFrEF), beta blockers are often preferred over calcium channel blockers due to their potential negative inotropic effects 2, 4.
- Studies have compared the effectiveness and safety of IV metoprolol and diltiazem in patients with AFib and RVR, with some finding similar safety and effectiveness outcomes between the two groups 5, 6.
- However, other studies have found that diltiazem may result in greater heart rate reductions and more frequent achievement of heart rate control compared to metoprolol 6.
- The choice of treatment should be individualized based on the patient's clinical situation, with consideration of factors such as myocardial ischemia, myocardial infarction, hyperthyroidism, and bronchial asthma 3.
Pharmacological Management Options
- Beta blockers, such as metoprolol, are commonly used for acute ventricular rate control in atrial fibrillation and atrial flutter 2, 3, 6, 4.
- Non-dihydropyridine calcium channel blockers, such as diltiazem, are also effective for acute ventricular rate control, but may be avoided in patients with HFrEF due to their potential negative inotropic effects 2, 3.
- Digoxin may be used as an adjunctive therapy, but is generally less effective as a single agent in the acute setting 3.