What is an acceptable ventricular rate for a patient with atrial fibrillation (AF) and a fibrillating right ventricular rate (RVR)?

From the Guidelines

For a patient with atrial fibrillation (AF) and rapid ventricular rate (RVR), the acceptable ventricular rate target is typically less than 110 beats per minute (bpm) at rest, with a goal of achieving a rate between 60-100 bpm. This recommendation is based on the most recent guidelines, including the 2024 ESC guidelines for the management of atrial fibrillation 1. The choice of rate control medication depends on the patient's left ventricular ejection fraction (LVEF), with beta-blockers, diltiazem, verapamil, or digoxin recommended for patients with LVEF >40% 1. In patients with LVEF ≤40%, beta-blockers and/or digoxin are recommended 1. Some key points to consider when managing AF and RVR include:

• The importance of rate control in preventing tachycardia-induced cardiomyopathy, heart failure, and hemodynamic compromise
• The use of lenient rate control with a resting heart rate of <110 bpm as the initial target for patients with AF 1
• The consideration of combination rate control therapy if a single drug does not control symptoms or heart rate 1
• The potential use of atrioventricular node ablation and cardiac resynchronization therapy in severely symptomatic patients with permanent AF and at least one hospitalization for heart failure 1. Overall, the management of AF and RVR requires a tailored approach, taking into account the patient's individual characteristics, symptoms, and comorbidities.

From the Research

Acceptable Ventricular Rate for Atrial Fibrillation (AF) and Fibrillating Right Ventricular Rate (RVR)

• The acceptable ventricular rate for a patient with atrial fibrillation (AF) and a fibrillating right ventricular rate (RVR) is typically considered to be less than 100 beats per minute (bpm) at rest 2.
• However, some studies suggest that lower resting rates may be appropriate, and the optimal heart rate during atrial fibrillation remains unknown 3.
• A study published in 2021 found that a rate less than 100 bpm within 1 hour of treatment was achieved in patients with acute atrial fibrillation with rapid ventricular rate using intravenous diltiazem, metoprolol, or verapamil 4.
• Another study published in 2001 compared the rate-lowering effect of diltiazem and amiodarone in critically ill patients with atrial tachyarrhythmias, and found that sufficient rate control can be achieved using either diltiazem or amiodarone 5.

Factors Influencing Rate Control

• The choice of rate control agent depends on individual patient factors, clinical situation, and comorbidities 6.
• Beta-blockers are often used for rate control, but may have reduced efficacy and safety issues in certain patient populations 2.
• Non-dihydropyridine calcium channel blockers may be contraindicated in patients with heart failure and systolic dysfunction 2.
• Digoxin may be useful in certain situations, such as in the presence of hypotension or absolute contraindication to beta-blocker treatment 2.

Outcome and Quality of Life

• A study published in 2009 found that there were no differences in terms of cardiovascular morbidity, mortality, and quality of life between patients with persistent atrial fibrillation who achieved a mean resting heart rate of less than 80 bpm versus those who achieved a rate of 80 bpm or higher 3.
• Another study published in 2021 found that there was no difference in achieving rate control when using intravenous diltiazem, metoprolol, or verapamil in patients with acute atrial fibrillation with rapid ventricular rate 4.