From the Guidelines
For a patient with atrial fibrillation with rapid ventricular response (AFib with RVR), the first-line treatment is rate control with intravenous beta-blockers or calcium channel blockers, as recommended by the 2024 ESC guidelines 1. The goal of treatment is to slow the ventricular rate and improve symptoms.
- The medications of choice are beta-blockers, such as metoprolol 5-10 mg IV over 2-5 minutes (may repeat up to 3 doses), or calcium channel blockers, such as diltiazem 0.25 mg/kg IV over 2 minutes (followed by 5-15 mg/hr infusion) 1.
- These medications slow conduction through the AV node, reducing ventricular rate and alleviating symptoms. If the patient is hemodynamically unstable (hypotensive, altered mental status, chest pain, or heart failure), immediate synchronized cardioversion at 120-200 joules is indicated instead, as it is a life-saving intervention. Second-line treatments include amiodarone (150 mg IV over 10 minutes, followed by 1 mg/min infusion for 6 hours, then 0.5 mg/min) if first-line agents fail or are contraindicated, as it has been shown to be effective in controlling heart rate and rhythm in patients with AFib 1.
- Digoxin (0.5 mg IV initially, then 0.25 mg IV every 6 hours up to 1.5 mg total) may be considered in patients with heart failure, though it has a slower onset of action and its use is generally limited to patients with severe left ventricular dysfunction 1. Concurrent anticoagulation should be initiated based on CHA₂DS₂-VASc score unless contraindicated, as recommended by the 2024 ESC guidelines 1, to reduce the risk of stroke and thromboembolism. It is essential to note that the choice of treatment should be individualized based on the patient's clinical presentation, medical history, and comorbidities, and that a multidisciplinary approach to care is recommended to ensure optimal outcomes 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 first line treatment for a patient with atrial fibrillation (AFib) and rapid ventricular response (RVR) is not explicitly stated in the provided drug label. However, based on the information provided, digoxin can be used to slow the rapid ventricular response rate in patients with chronic atrial fibrillation.
- The dose of digoxin for this purpose is between 0.25 to 0.75 mg/day. There is no information in the provided drug label about the second line treatment for AFib with RVR 2.
From the Research
First Line Treatments
- Intravenous beta blockers and calcium channel blockers are equally effective in rapidly controlling the ventricular rate in acute AF in selected individuals 3
- Metoprolol and diltiazem are the two most common agents used for rate control in patients with atrial fibrillation and rapid ventricular rate (RVR) 4
- In patients with heart failure, diltiazem is not recommended due to its negative inotropic effects, but studies have shown similar safety and effectiveness outcomes between diltiazem and metoprolol in this population 5
Second Line Treatments
- The addition of digoxin to the regimen can cause a favorable outcome, but digoxin as a single agent is generally inefficacious in slowing the ventricular rate in acute AF 3
- Concomitant parenteral calcium channel blockers and beta blockers can be used to achieve rate control in patients with atrial fibrillation or flutter with RVR 6
- In patients with heart failure with reduced ejection fraction (HFrEF), metoprolol may be preferred over diltiazem due to the potential negative inotropic effects of diltiazem 7
Special Considerations
- In patients with ventricular preexcitation syndrome associated with rapid ventricular rate due to AF, the drug of choice is intravenous procainamide 3
- Cardioversion is the treatment of choice in all cases of AF with rapid ventricular rate when the clinical condition is unstable or hemodynamically compromised 3
- Radiofrequency ablation of the AV node or anomalous tract may be considered in refractory or high-risk subjects as a last resort 3