From the Guidelines
For new onset atrial fibrillation with rapid ventricular response (AFib with RVR), the initial treatment should focus on rate control using beta-blockers, diltiazem, verapamil, or digoxin, as recommended by the 2024 ESC guidelines 1. The goal of rate control is to reduce symptoms and prevent complications associated with rapid ventricular response.
- For patients with left ventricular ejection fraction (LVEF) >40%, beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs to control heart rate and reduce symptoms 1.
- For patients with LVEF ≤40%, beta-blockers and/or digoxin are recommended to control heart rate and reduce symptoms 1. It is essential to assess the patient's hemodynamic stability and consider anticoagulation based on the CHA₂DS₂-VASc score, as well as rhythm control strategies, such as electrical cardioversion or antiarrhythmic medications, in appropriate candidates. The 2014 AHA/ACC/HRS guideline also supports the use of a combination of digoxin and a beta blocker to control resting and exercise heart rate in patients with AF 1. However, the most recent and highest-quality evidence from the 2024 ESC guidelines 1 prioritizes beta-blockers, diltiazem, verapamil, or digoxin as the initial treatment for rate control in patients with new onset AFib with RVR.
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 treatment for new onset atrial fibrillation (a fib) with rapid ventricular response (RVR) is not directly addressed in the provided drug label, as it specifically mentions chronic atrial fibrillation. However, based on the available information, digoxin may be used to slow the rapid ventricular response rate in atrial fibrillation.
- The dose of digoxin for this purpose is between 0.25 to 0.75 mg/day.
- It is essential to note that the label does not provide direct guidance for new onset atrial fibrillation, and the use of digoxin in this context should be approached with caution 2.
From the Research
Treatment for New Onset Atrial Fibrillation with Rapid Ventricular Response
The treatment for new onset atrial fibrillation (a fib) with rapid ventricular response (RVR) aims to reduce patients' symptoms and prevent both embolism and deterioration of any underlying heart disease 3. The primary goals are to control the heart rate and prevent thromboembolic events.
Rate Control vs. Rhythm Control
Rate control is often the preferred treatment option, especially in patients with stable atrial fibrillation 3, 4. Rhythm control, on the other hand, may be considered in symptomatic patients with recent or paroxysmal atrial fibrillation who are under 65 and have no signs or symptoms of coronary heart disease 3.
Medications for Rate Control
The following medications can be used for rate control:
- Beta-blockers (e.g., metoprolol) 5, 6, 4
- Calcium channel blockers (e.g., diltiazem, verapamil) 3, 5, 7, 4
- Digoxin 3, 4
Diltiazem for Rate Control
Diltiazem is a commonly used medication for rate control in atrial fibrillation with RVR 7. A low dose of diltiazem (≤ 0.2 mg/kg) may be as effective as the standard dose in controlling rapid AF and reduce the risk of hypotension 7.
Anticoagulation Therapy
Anticoagulation therapy is an essential component of management for patients with atrial fibrillation, especially those with a high risk of thromboembolic events 3, 6. Direct oral anticoagulants are the first-line medication class for anticoagulation 6.
Disposition and Risk Assessment
Disposition can be challenging, and several risk assessment tools (e.g., CHA2DS2-VASc, RED-AF, AFFORD, and the AFTER scores) are available to assist with disposition decisions 6.
Key Considerations
Key considerations in the management of atrial fibrillation with RVR include: