From the Guidelines
Treatment for atrial fibrillation with rapid ventricular response (AFib with RVR) should prioritize rate control using beta-blockers, diltiazem, verapamil, or digoxin as first-choice drugs, depending on the patient's left ventricular ejection fraction (LVEF) and clinical presentation, as recommended by the 2024 ESC guidelines 1. The primary goal in managing AFib with RVR is to control the ventricular rate and alleviate symptoms.
- For patients with LVEF >40%, beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-line treatments to control heart rate and reduce symptoms 1.
- In patients with LVEF ≤40%, beta-blockers and/or digoxin are preferred for rate control 1. Key considerations in the treatment approach include:
- The need for immediate rate control in acute settings, which may involve intravenous administration of these medications.
- The importance of anticoagulation therapy to prevent stroke, based on the patient's stroke risk assessment using the CHA₂DS₂-VASc score.
- The potential role of rhythm control strategies, including electrical cardioversion or antiarrhythmic medications, in specific clinical scenarios, such as hemodynamic instability or failed rate control. It is essential to tailor the treatment strategy to the individual patient's clinical profile, taking into account factors such as symptoms, hemodynamics, and comorbidities, as well as the latest guideline recommendations 1.
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 treatment for Atrial Fibrillation (Afib) with Rapid Ventricular Response (RVR) is digoxin, which slows the rapid ventricular response rate in a linear dose-response fashion from 0.25 to 0.75 mg/day 2.
From the Research
Treatment Options for Atrial Fibrillation with Rapid Ventricular Response
The treatment for Atrial Fibrillation (Afib) with Rapid Ventricular Response (RVR) involves several options, including:
- Rate control using beta blockers or calcium channel blockers 3, 4, 5, 6, 7
- Rhythm control using cardioversion or anti-arrhythmic medications 4, 7
- Anticoagulation to prevent stroke 4
Rate Control
Rate control is achieved using beta blockers or calcium channel blockers, with the goal of reducing the heart rate to less than 100 beats per minute. Studies have shown that:
- Diltiazem may achieve rate control faster than metoprolol 3, 5
- Diltiazem may be more effective in reducing heart rate than metoprolol in patients with heart failure 5
- A weight-based dose of diltiazem (≥ 0.13 mg/kg) may be more effective in achieving heart rate control than a non-weight-based dose 6
Rhythm Control
Rhythm control involves converting the abnormal heart rhythm back to a normal sinus rhythm using cardioversion or anti-arrhythmic medications. Cardioversion is the treatment of choice in hemodynamically unstable patients 4, 7.
Anticoagulation
Anticoagulation is an important component of management to prevent stroke, and several tools are available to assist with this decision, including the CHA2DS2-VASc score 4. Direct oral anticoagulants are the first-line medication class for anticoagulation 4.
Considerations
When selecting a treatment option, clinicians must consider the individual patient, clinical situation, and comorbidities, including heart failure 3, 5.