What is the treatment for patients with Atrial Flutter (AFlutter) with Rapid Ventricular Response (RVR) and decompensated Heart Failure with reduced Ejection Fraction (HFrEF)?

From the Guidelines

The treatment for patients with atrial flutter with rapid ventricular response (AFlutter RVR) and decompensated heart failure with reduced ejection fraction (HFrEF) should prioritize immediate rate control and management of heart failure symptoms, with a focus on intravenous rate-controlling agents such as beta-blockers and/or digoxin, as recommended by the 2024 ESC guidelines 1.

Key Considerations

• The primary goal is to control the ventricular rate and alleviate heart failure symptoms, while also addressing the underlying heart failure.
• Beta-blockers and digoxin are recommended for rate control in patients with AF and LVEF ≤40% 1.
• Diuretics, such as furosemide, should be administered to reduce fluid overload and improve symptoms.
• For patients with severe symptoms or hemodynamic instability, synchronized electrical cardioversion may be necessary.

Long-term Management

• Once stabilized, anticoagulation should be initiated based on stroke risk assessment.
• Guideline-directed medical therapy for HFrEF, including ACE inhibitors/ARBs, beta-blockers, aldosterone antagonists, and SGLT2 inhibitors, should be optimized.
• Catheter ablation may be considered for definitive treatment of atrial flutter.

Evidence-based Recommendations

• The 2024 ESC guidelines recommend beta-blockers and/or digoxin for rate control in patients with AF and LVEF ≤40% 1.
• The 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure recommend diuretics to improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion 1.
• The 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation recommends a rhythm-control strategy for patients who develop HF as a result of AF with a rapid ventricular response 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment for AFlutter RVR and Decompensated HFrEF

• The treatment for patients with atrial flutter (AFlutter) with rapid ventricular response (RVR) and decompensated heart failure with reduced ejection fraction (HFrEF) involves managing the acute decompensated heart failure and controlling the heart rate 2.
• Pharmacological management options for AFRVR in patients with acute decompensated heart failure include diltiazem and metoprolol, with diltiazem showing a therapeutic response in 100% of patients in one study, compared to 0% in the placebo group 3.
• However, another study found that worsening heart failure symptoms occurred more frequently in patients receiving diltiazem compared to metoprolol (33% vs 15%, p = 0.019) 4.
• Beta blockers, such as metoprolol, are recommended as first-line therapy for acute rate control in AFRVR patients with HFrEF, due to their additional hemodynamic effect of neurohormonal blockade, which provides a long-term mortality benefit to HFrEF patients 5.
• Diltiazem may be considered as a second-line option, although the relative paucity of data calls for further research to validate this conclusion 5.
• Verapamil should be avoided in this setting until more data are available 5.
• Nonpharmacological management options, such as electrical cardioversion, may also be considered, although data on its effectiveness in this patient population are limited 3.

Comparison of Treatment Options

• A study comparing metoprolol and diltiazem in the acute management of AFlutter with RVR in patients with HFrEF found no difference in successful rate control within 30 minutes of medication administration (62% vs 50%, p = 0.49) 6.
• Another study found that the incidence of adverse effects, including hypotension and worsening heart failure symptoms, was similar between diltiazem and metoprolol (32% vs 21%, P = 0.217) 4.
• However, the diltiazem group had a higher incidence of worsening heart failure symptoms defined as increased oxygen requirement within four hours or initiation of inotropic support within 48 hours (33% vs 15%, P = 0.019) 4.

Clinical Considerations

• The choice of treatment for AFlutter RVR and decompensated HFrEF should be individualized based on the patient's clinical presentation and medical history 2.
• Patients with severe circulatory failure may require inotropic drugs or mechanical circulatory support 2.
• The use of nondihydropyridine calcium channel blockers, such as diltiazem, should be cautious in patients with HFrEF due to their potential negative inotropic effects 5.