From the Guidelines
The management of atrial fibrillation with rapid ventricular response (AFib with RVR) should prioritize rate control, rhythm control, and stroke prevention, with a focus on the AF-CARE pathway, which includes comorbidity and risk factor management, avoidance of stroke and thromboembolism, reduction of symptoms, and evaluation and dynamic reassessment, as outlined in the 2024 ESC guidelines 1.
Key Considerations
- Initial management should address hemodynamic stability, with immediate electrical cardioversion for unstable patients, as recommended in the guidelines 1.
- For stable patients, rate control can be achieved with AV nodal blocking agents, such as beta-blockers, digoxin, or diltiazem/verapamil, with the choice of agent depending on the patient's ejection fraction and other factors 1.
- Long-term management requires anticoagulation based on the CHA₂DS₂-VASc score, with direct oral anticoagulants (DOACs) preferred for most patients, unless they have mechanical heart valves or mitral stenosis, in which case vitamin K antagonists (VKAs) may be used 1.
- Rhythm control strategies may include cardioversion, antiarrhythmic medications, or catheter ablation for recurrent episodes, with the choice between rate and rhythm control depending on symptom severity, patient age, comorbidities, and AFib duration 1.
Treatment Options
- Rate control therapy: beta-blockers, digoxin, or diltiazem/verapamil can be used as initial therapy in the acute setting, as an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and symptoms 1.
- Rhythm control: consider in all suitable AF patients, explicitly discussing with patients all potential benefits and risks of cardioversion, antiarrhythmic drugs, and catheter or surgical ablation to reduce symptoms and morbidity 1.
- Anticoagulation: use full standard doses of DOACs unless the patient meets specific dose-reduction criteria, and avoid combining anticoagulants and antiplatelet agents unless necessary 1.
Monitoring and Follow-up
- Regular monitoring of heart rate, symptoms, and anticoagulation is necessary to optimize outcomes and minimize complications 1.
- Periodic reassessment of therapy and attention to new modifiable risk factors can help slow or reverse the progression of AF, increase quality of life, and prevent adverse outcomes 1.
From the Research
Management of Atrial Fibrillation with Rapid Ventricular Response
The management of atrial fibrillation (AFib) with rapid ventricular response (RVR) involves several strategies, including:
- Rate control using beta blockers or calcium channel blockers 2, 3, 4, 5, 6
- Rhythm control using cardioversion or antiarrhythmic medications 2, 4
- Anticoagulation to prevent stroke 4
Rate Control
Rate control is often achieved using intravenous (IV) non-dihydropyridine calcium channel blockers (CCB) or beta blockers (BB) 5. The choice of agent depends on the individual patient's clinical situation and comorbidities 3. Studies have shown that:
- Diltiazem may achieve rate control faster than metoprolol, but both agents are safe and effective 3
- Metoprolol had a lower failure rate than amiodarone and was superior to diltiazem in achieving rate control at 4 h 6
- In patients with heart failure with reduced ejection fraction (HFrEF), IV diltiazem and metoprolol had similar adverse effects, but diltiazem was associated with a higher incidence of worsening heart failure symptoms 5
Rhythm Control
Rhythm control involves converting the patient back to a normal sinus rhythm using cardioversion or antiarrhythmic medications 2, 4. Cardioversion is indicated in hemodynamically unstable patients, while elective cardioversion may be considered in select patients 4.
Anticoagulation
Anticoagulation is an important component of management to prevent stroke 4. Direct oral anticoagulants are the first-line medication class for anticoagulation, and several tools (e.g., CHA2DS2-VASc) are available to assist with this decision 4.
Disposition
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 4.
Key Considerations
Key considerations in the management of AFib with RVR include:
- Evaluating hemodynamic stability and differentiating primary and secondary AF with RVR 4
- Using troponin to determine the risk of adverse outcomes, but not universally testing patients at low risk of acute coronary syndrome or coronary artery disease 4
- Considering the individual patient's clinical situation and comorbidities when selecting a medication for rate control 3