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

From the Guidelines

Management of atrial fibrillation with rapid ventricular response (AFib with RVR) should prioritize rate control using intravenous beta-blockers or calcium channel blockers, with a focus on preventing complications and improving quality of life, as recommended by the most recent guidelines 1. The primary goal of treatment is to control the ventricular rate and prevent thromboembolic events.

• Rate control can be achieved using beta-blockers, such as metoprolol, or calcium channel blockers, such as diltiazem or verapamil, as initial therapy in the acute setting 1.
• In hemodynamically unstable patients, immediate electrical cardioversion with 120-200 joules is indicated, as it can rapidly restore a normal heart rhythm and improve cardiac output 1.
• Once stabilized, transition to oral medications for ongoing rate control, such as metoprolol 25-100 mg twice daily, diltiazem ER 120-480 mg daily, or verapamil ER 120-480 mg daily, can be considered 1.
• For rhythm control in selected patients, consider amiodarone, flecainide, propafenone, or sotalol based on cardiac function and comorbidities, with a focus on reducing symptoms and improving quality of life 1.
• Anticoagulation is essential for stroke prevention in most patients with AFib, with options including warfarin (target INR 2-3) or direct oral anticoagulants like apixaban 5 mg twice daily, rivaroxaban 20 mg daily, or dabigatran 150 mg twice daily, as recommended by the guidelines 1. The choice between rate and rhythm control strategies depends on symptom severity, duration of AFib, left atrial size, and patient preferences, with a focus on individualized care and shared decision-making 1.
• Beta-blockers and calcium channel blockers work by blocking AV nodal conduction, thereby reducing ventricular rate and improving cardiac output by allowing adequate ventricular filling time 1.
• The most recent guidelines emphasize the importance of a patient-centered approach, with a focus on education, shared decision-making, and dynamic evaluation to improve outcomes and quality of life for patients with AFib 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 management of atrial fibrillation (Afib) with rapid ventricular response (RVR) includes the use of digoxin to slow the rapid ventricular response rate in a linear dose-response fashion from 0.25 to 0.75 mg/day 2.

• Key points:
  • Digoxin should be used with caution and its dose adjusted according to the patient's age, sex, lean body weight, and serum creatinine.
  • The use of digoxin may be associated with a trend to increase time to all-cause death or hospitalization.
  • Digoxin should not be used for the treatment of multifocal atrial tachycardia.
• Alternative options may include other medications such as sotalol or verapamil, but their use in this context is not directly supported by the provided drug labels.

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 beta blockers or calcium channel blockers 3, 4, 5, 6
• Rhythm control using antiarrhythmic drugs or cardioversion 3, 4, 7
• Anticoagulation to prevent stroke 4

Pharmacological Management

Pharmacological management of Afib with RVR includes:

• Intravenous beta blockers, such as metoprolol 5, 6
• Intravenous calcium channel blockers, such as diltiazem 5, 6 and verapamil 7
• Digoxin, which can be added to the regimen but is generally inefficacious as a single agent 3
• Procainamide, which is the drug of choice in ventricular preexcitation syndrome associated with rapid ventricular rate due to Afib 3

Non-Pharmacological Management

Non-pharmacological management of Afib with RVR includes:

• Cardioversion, which is the treatment of choice in hemodynamically unstable patients 3, 4
• Radiofrequency ablation of the AV node or anomalous tract, which may be considered in refractory or high-risk subjects as a last resort 3
• Elective cardioversion, which is a safe option for select patients and may reduce Afib symptoms and risk of Afib recurrence 4

Patient Assessment and Disposition

Patient assessment and disposition involve:

• Evaluating hemodynamic stability 4
• Determining the risk of adverse outcomes using tools such as troponin testing 4
• Using risk assessment tools, such as RED-AF, AFFORD, and the AFTER scores, to assist with disposition decisions 4