What is the management of atrial fibrillation (AFib) with rapid ventricular response (RVR)?

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 by rate and rhythm control, and evaluation and dynamic reassessment, as recommended by the 2024 ESC guidelines 1. The initial management of AFib with RVR typically involves rate control with medications such as intravenous beta-blockers, calcium channel blockers, or digoxin.

• Beta-blockers, such as metoprolol, are often used as first-line therapy for rate control, with a dose of 5-15 mg IV.
• Calcium channel blockers, such as diltiazem, can also be used, with a dose of 0.25 mg/kg IV bolus, followed by infusion at 5-15 mg/hour.
• Digoxin can be used as an adjunct to beta-blockers, with a dose of 0.5 mg IV loading dose, followed by 0.25 mg every 6 hours. For hemodynamically unstable patients, immediate electrical cardioversion with 120-200 joules is indicated. Once stabilized, patients should be assessed for stroke risk using the CHA₂DS₂-VASc score to determine the need for anticoagulation, with direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, or dabigatran preferred over vitamin K antagonists (VKAs) like warfarin, unless contraindicated 1. Long-term management may include continued rate control medications, rhythm control with antiarrhythmic drugs like amiodarone, or catheter ablation for refractory cases.
• The choice between rate and rhythm control strategies depends on symptom severity, patient age, comorbidities, and patient preference, with rate control often preferred in older patients with fewer symptoms, and rhythm control may benefit younger patients with more symptomatic AFib. The 2024 ESC guidelines recommend a patient-centered approach, with shared decision-making and a multidisciplinary team, and emphasize the importance of education for patients, family members, caregivers, and healthcare professionals to aid in shared decision-making 1. In patients with AFib and heart failure, a rhythm-control strategy may be considered, with AF catheter ablation potentially leading to an improvement in left ventricular function and quality of life, although the evidence is less strong compared to the 2024 ESC guidelines 1.

From the FDA Drug Label

Transition to Further Antiarrhythmic Therapy. Transition to other antiarrhythmic agents following administration of diltiazem hydrochloride injection is generally safe. However, reference should be made to the respective agent manufacturer's package insert for information relative to dosage and administration In controlled clinical trials, therapy with antiarrhythmic agents to maintain reduced heart rate in atrial fibrillation or atrial flutter or for prophylaxis of PSVT was generally started within 3 hours after bolus administration of diltiazem hydrochloride injection. The management of atrial fibrillation (AFib) with rapid ventricular response (RVR) may involve the use of diltiazem hydrochloride injection to reduce the heart rate.

• Diltiazem hydrochloride injection can be used to control the ventricular rate in AFib or atrial flutter.
• Therapy with other antiarrhythmic agents can be started within 3 hours after bolus administration of diltiazem hydrochloride injection to maintain a reduced heart rate.
• It is recommended to dose patients on an individual basis and refer to the respective manufacturer's package insert for information relative to dosage and administration 2.

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 medications such as beta blockers or calcium channel blockers 3, 4, 5
• Rhythm control using cardioversion or antiarrhythmic medications 4, 6
• Anticoagulation to prevent stroke 6

Medications for Rate Control

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

• Diltiazem: a calcium channel blocker that can be effective in controlling the ventricular rate 3, 5, 7
• Beta blockers: such as metoprolol, which can also be effective in controlling the ventricular rate 5
• Digoxin: which can be used in combination with other medications, but is generally not effective as a single agent 4

Considerations for Management

When managing AFib with RVR, it is important to consider the following:

• Hemodynamic stability: patients who are hemodynamically unstable may require emergent cardioversion 4, 6
• Underlying cardiovascular disease: patients with underlying cardiovascular disease may require more aggressive management 6
• Comorbidities: such as kidney disease or liver disease, which can affect the choice of medication 6

Prehospital Management

Prehospital administration of diltiazem can be safe and effective in controlling the ventricular rate in AFib with RVR, when strict protocols are followed 7

• A protocol-directed dose of 0.25mg/kg of diltiazem (maximum of 20mg) can be effective in controlling the ventricular rate 7
• Adverse events, such as hypotension, can occur, but are less common when protocols are followed 7