What should I do for atrial fibrillation (Afib) with rapid ventricular response (RVR) and hypotension?

From the Guidelines

For atrial fibrillation with rapid ventricular response (Afib RVR) and hypotension, immediate intervention with synchronized cardioversion at 120-200 joules is recommended if the patient is severely unstable with signs of shock, as stated in the 2014 AHA/ACC/HRS guideline 1. When managing Afib RVR with hypotension, it is crucial to assess the patient's hemodynamic stability.

• If the patient is severely unstable, proceed with synchronized cardioversion.
• If the patient is less unstable but still hypotensive, consider IV rate control with diltiazem or metoprolol, but use beta-blockers cautiously in hypotensive patients, as recommended in the guideline for patients with heart failure 1. Some key points to consider in the management of Afib RVR with hypotension include:
• Providing IV fluid resuscitation with normal saline boluses to support blood pressure.
• Correcting any electrolyte abnormalities, particularly potassium and magnesium.
• Considering anticoagulation based on CHA₂DS₂-VASc score to prevent thromboembolism, as recommended in the guideline for patients with AF complicating ACS 1. The rapid heart rate in Afib RVR reduces diastolic filling time, decreasing cardiac output and causing hypotension.
• Controlling the rate or converting to sinus rhythm improves cardiac filling and stroke volume, thereby restoring blood pressure. In the context of Afib RVR with hypotension, the guideline recommends the use of IV beta blockers or nondihydropyridine calcium channel antagonists to slow ventricular response, with caution in patients with overt congestion, hypotension, or HFrEF 1. However, in cases where the patient is hemodynamically unstable, cardioversion is the preferred initial treatment, as it can rapidly restore a normal heart rhythm and improve cardiac output.

From the FDA Drug Label

Hypotension is the most common adverse reaction seen with intravenous amiodarone. Treat hypotension initially by slowing the infusion; additional standard therapy may be needed, including the following: vasopressor drugs, positive inotropic agents, and volume expansion.

For atrial fibrillation (Afib) with rapid ventricular response (RVR) and hypotension, the treatment approach should focus on addressing the hypotension.

• Slow the infusion of amiodarone if it is being used.
• Consider adding vasopressor drugs, positive inotropic agents, and volume expansion as needed to manage hypotension. It is essential to monitor the patient closely and adjust the treatment plan accordingly. 2 2 2

From the Research

Management of Atrial Fibrillation with Rapid Ventricular Response and Hypotension

• Atrial fibrillation (AF) with rapid ventricular response (RVR) and hypotension is a serious condition that requires prompt management in the emergency department (ED) 3.
• The primary goal of treatment is to control the heart rate and improve hemodynamic stability 3, 4.
• Intravenous (IV) diltiazem is often used as the initial treatment for AF with RVR, and the route of administration after the initial IV loading dose may influence patient disposition from the ED 5.
• A study comparing oral (PO) immediate-release and IV continuous infusion diltiazem found that PO immediate-release diltiazem was associated with a lower rate of treatment failure at four hours than IV continuous infusion in patients with AF with RVR 5.

Treatment Options

• Diltiazem dosing strategies have been investigated, and a weight-based dose of ≥ 0.13 mg/kg was associated with improved heart rate control compared to < 0.13 mg/kg 6.
• Prehospital advanced life support (ALS) rate or rhythm control interventions, including medications such as calcium channel blockers and beta blockers, can improve outcomes for patients presenting with AF-RVR 4.
• A comparison of IV push diltiazem and metoprolol for AF rate control found that both agents caused similar systolic blood pressure reduction and hypotension, but rate control was achieved more often with diltiazem 7.

Considerations for Hypotension

• Hypotension is a potential complication of treatment for AF with RVR, and clinicians should carefully monitor blood pressure and adjust treatment accordingly 3, 4, 7.
• A study found that prehospital ALS interventions were associated with more frequent hypotension, but this resolved before ED arrival in most cases 4.
• Clinicians should weigh the benefits and risks of different treatment options and consider individual patient factors, such as underlying medical conditions and medication use, when managing AF with RVR and hypotension 3, 6, 7.