What is the treatment plan for a patient with atrial fibrillation (AFib) and tachycardia, currently on Xarelto (rivaroxaban)?

Management of Atrial Fibrillation with Tachycardia in a Patient on Rivaroxaban

For a patient with atrial fibrillation and tachycardia (heart rate 119 bpm) who is currently on Xarelto (rivaroxaban), the treatment plan should focus on achieving adequate rate control with beta blockers or non-dihydropyridine calcium channel blockers while maintaining anticoagulation with rivaroxaban.

Rate Control Strategy

First-Line Medications

• Beta blockers are the most effective agents for rate control, achieving heart rate targets in approximately 70% of patients 1

  • Metoprolol: 2.5-5.0 mg IV bolus (up to 3 doses) followed by oral maintenance of 25-100 mg twice daily
  • Atenolol: 25-100 mg daily
  • Carvedilol: 3.125-25 mg twice daily

• Non-dihydropyridine calcium channel blockers are effective alternatives, especially in patients with bronchospasm or COPD 1

  • Diltiazem: 15-25 mg IV bolus followed by 60-120 mg three times daily (or 120-360 mg daily modified release)
  • Verapamil: 2.5-10 mg IV bolus followed by 40-120 mg three times daily (or 120-480 mg daily modified release)

Second-Line Options

• Digoxin: Consider adding if monotherapy with beta blockers or calcium channel blockers is insufficient 1

  • Less effective during states of high sympathetic tone
  • More appropriate for sedentary patients or those with heart failure
  • Dosing: 0.5 mg IV bolus followed by 0.0625-0.25 mg daily oral maintenance

• Combination therapy: Beta blocker plus digoxin (or non-dihydropyridine calcium channel blocker plus digoxin for patients with HFpEF) is reasonable to control both resting and exercise heart rate 1

Heart Rate Targets

• Resting heart rate: 60-100 bpm
• During moderate exercise: 90-115 bpm 2
• Assessment of heart rate control during exercise is useful in symptomatic patients 1

Anticoagulation Management

• Continue rivaroxaban as the patient is already on this medication 3
• Ensure proper dosing:
  • For non-valvular atrial fibrillation: 20 mg once daily with evening meal (or 15 mg daily if CrCl 15-50 mL/min)
  • Take at the same time each day to maintain consistent anticoagulation 3

Additional Considerations

For Refractory Cases

• If rate control cannot be achieved with pharmacological therapy:
  • Amiodarone: Can be useful when other measures are unsuccessful or contraindicated 1
  • AV node ablation with ventricular pacing: Consider when pharmacological therapy is insufficient or not tolerated 1

Special Circumstances

• If the patient has heart failure with reduced ejection fraction:

  • Avoid non-dihydropyridine calcium channel blockers
  • Use beta blockers cautiously
  • Consider digoxin or amiodarone for acute rate control 1

• If tachycardia-induced cardiomyopathy is suspected:

  • More aggressive rate control or rhythm control strategy is reasonable 1

Follow-up Plan

• Reassess rate control within 10 days of treatment initiation
• Monitor for:
  • Effectiveness of rate control (both at rest and with activity)
  • Symptoms improvement
  • Medication side effects
  • Anticoagulation efficacy and safety 2

Common Pitfalls to Avoid

• Don't discontinue anticoagulation when rate control is achieved
• Don't rely solely on resting heart rate assessment; evaluate rate control during activity as well
• Avoid non-dihydropyridine calcium channel blockers in patients with decompensated heart failure
• Don't perform AV node ablation without first attempting pharmacological rate control 1