From the Guidelines
For atrial fibrillation with rapid ventricular response (Afib RVR) in a patient with low ejection fraction (EF), the primary goal is to control the heart rate while addressing the underlying heart failure, and beta-blockers and/or digoxin are recommended as first-choice drugs to control heart rate and reduce symptoms 1.
Treatment Approach
The treatment approach for Afib RVR with low EF involves a combination of rate control, rhythm control, and management of underlying heart failure.
- Rate control can be achieved with beta-blockers such as metoprolol (starting at 12.5-25mg twice daily) or carvedilol (starting at 3.125mg twice daily), titrating slowly to target heart rates of 60-100 beats per minute.
- Add digoxin (0.125-0.25mg daily) if rate control remains inadequate, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1.
- For patients with severe heart failure symptoms, consider amiodarone (loading dose of 400mg twice daily for 1 week, then 200mg daily) for both rate and rhythm control, as suggested by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.
Anticoagulation and Heart Failure Management
- Anticoagulation is essential with options including warfarin (target INR 2-3) or direct oral anticoagulants like apixaban (5mg twice daily).
- Diuretics such as furosemide (20-40mg daily) should be used to manage fluid overload.
- An ACE inhibitor or ARB plus a beta-blocker and aldosterone antagonist are cornerstone therapies for the underlying low EF.
- Consider cardioversion once the patient is adequately anticoagulated if symptoms persist despite rate control, as the rapid heart rate in Afib RVR can worsen heart failure by reducing diastolic filling time and cardiac output, creating a vicious cycle that requires prompt intervention to prevent further deterioration of cardiac function 1.
From the FDA Drug Label
The acute effectiveness of amiodarone HCl injection in suppressing recurrent VF or hemodynamically unstable VT is supported by two randomized, parallel, dose-response studies of approximately 300 patients each In patients with severe left ventricular dysfunction, the pharmacokinetics of amiodarone are not significantly altered but the terminal disposition t½ of DEA is prolonged No correlations were seen between the baseline ejection fraction and the occurrence of clinically significant hypotension during infusion of amiodarone HCl injection
The treatment options for Atrial Fibrillation (Afib) with Rapid Ventricular Response (RVR) and low Ejection Fraction (EF) may include amiodarone.
- Key points:
- Amiodarone can be effective in suppressing recurrent VF or hemodynamically unstable VT.
- The pharmacokinetics of amiodarone are not significantly altered in patients with severe left ventricular dysfunction.
- Close clinical monitoring is prudent for patients with severe left ventricular dysfunction. 2
From the Research
Treatment Options for Atrial Fibrillation (Afib) with Rapid Ventricular Response (RVR) and Low Ejection Fraction (EF)
- The primary goal of treatment is to alleviate symptoms, improve quality of life, and minimize morbidity associated with Afib 3.
- For patients with Afib and RVR, rate control is crucial to prevent complications such as hypoperfusion and cardiac ischemia 4, 5.
- Beta-blockers or nondihydropyridine calcium channel blockers are the initial therapy for rate control of Afib and AFL in most patients without a history of myocardial infarction or left ventricular dysfunction 3.
- In patients with low EF (<35%), amiodarone is the only recommended drug for maintenance of sinus rhythm 3.
- For rate control, treatment should aim for a resting heart rate of <100 beats per minute 3.
- Diltiazem and metoprolol are effective agents for rate control, with diltiazem likely achieving rate control faster than metoprolol 6.
- Oral immediate-release diltiazem may be associated with a lower rate of treatment failure compared to IV continuous infusion diltiazem after an initial IV loading dose 7.
- Anticoagulation is an important component of management, and direct oral anticoagulants are the first-line medication class for anticoagulation 4, 5.
- Disposition decisions can be challenging, and several risk assessment tools are available to assist with disposition decisions 4, 5.