What is the recommended treatment for acute atrial fibrillation (AFib) with rapid ventricular response (RVR)?

From the Guidelines

The recommended initial treatment for acute atrial fibrillation (AFib) with rapid ventricular response (RVR) is intravenous rate-controlling medications, such as beta blockers or nondihydropyridine calcium channel antagonists, to slow the ventricular response to AF in the acute setting, with caution needed in patients with overt congestion, hypotension, or HF with reduced LVEF 1.

Key Considerations

• The choice of medication depends on the patient's underlying condition, such as heart failure with preserved ejection fraction (HFpEF) or reduced ejection fraction.
• In patients with HFpEF, a nondihydropyridine calcium channel antagonist may be preferred, while in patients with reduced LVEF, a beta blocker may be more suitable.
• Digoxin or amiodarone may be used for rate control in patients with congestive heart failure, but with caution due to potential risks 1.

Management Approach

• For hemodynamically unstable patients, immediate synchronized cardioversion at 120-200 joules is indicated, as recommended by the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1.
• After achieving rate control, anticoagulation should be considered based on stroke risk using the CHA₂DS₂-VASc score.
• Addressing precipitating factors such as electrolyte abnormalities, thyroid dysfunction, infection, or alcohol consumption is essential for comprehensive management and prevention of recurrence.

Medication Options

• Beta blockers: metoprolol (5-15 mg IV) or esmolol (500 mcg/kg IV bolus, followed by infusion)
• Nondihydropyridine calcium channel antagonists: diltiazem (0.25 mg/kg IV over 2 minutes, followed by infusion if needed)
• Digoxin or amiodarone for rate control in patients with congestive heart failure, with caution due to potential risks 1.

From the FDA Drug Label

Diltiazem Hydrochloride Injection or Diltiazem Hydrochloride for Injection are indicated for the following: Atrial Fibrillation or Atrial Flutter Temporary control of rapid ventricular rate in atrial fibrillation or atrial flutter

Unless otherwise contraindicated, appropriate vagal maneuvers should be attempted prior to administration of diltiazem hydrochloride injection

For either indication and particularly when employing continuous intravenous infusion, the setting should include continuous monitoring of the ECG and frequent measurement of blood pressure. A defibrillator and emergency equipment should be readily available

The recommended treatment for acute atrial fibrillation (AFib) with rapid ventricular response (RVR) is temporary control of rapid ventricular rate using diltiazem hydrochloride injection.

• Vagal maneuvers should be attempted prior to administration of diltiazem hydrochloride injection, unless otherwise contraindicated.
• The setting for administration should include continuous monitoring of the ECG and frequent measurement of blood pressure, with a defibrillator and emergency equipment readily available 2.

From the Research

Acute Treatment of AFib with RVR

The recommended treatment for acute atrial fibrillation (AFib) with rapid ventricular response (RVR) involves rate control and rhythm control strategies.

• Rate control is often the first-line option, using medications such as digoxin, beta-blockers, or calcium channel blockers (diltiazem or verapamil) to slow the heart rate 3.
• The choice of medication depends on the individual patient's condition, comorbidities, and clinical situation 4.
• Diltiazem is a commonly used medication for rate control in AFib with RVR, and low-dose diltiazem may be as effective as the standard dose in controlling rapid AF while reducing the risk of hypotension 5.
• Other options for rate control include metoprolol and verapamil, which may be used as alternatives to diltiazem, especially in cases where diltiazem is not available 6.
• In patients with relative contraindications for calcium channel blockers or beta-blockers, intravenous amiodarone may be a suitable option for rate control, with a higher treatment success rate and faster response compared to IV digoxin 7.

Rate Control Medications

The following medications are commonly used for rate control in AFib with RVR:

• Diltiazem: a calcium channel blocker that can be administered intravenously to rapidly control heart rate 5, 6.
• Metoprolol: a beta-blocker that can be used as an alternative to diltiazem, especially in cases where diltiazem is not available 4, 6.
• Verapamil: a calcium channel blocker that can be used as an alternative to diltiazem, especially in cases where diltiazem is not available 6.
• Amiodarone: an antiarrhythmic medication that can be used for rate control in patients with relative contraindications for calcium channel blockers or beta-blockers 7.
• Digoxin: a cardiac glycoside that can be used for rate control, although it may have a slower onset of action and lower treatment success rate compared to amiodarone 7.