From the Guidelines
Atrial fibrillation (AF) with a rapid ventricular response can be caused by various conditions, including hyperthyroidism, acute infections, stimulant use, electrolyte abnormalities, heart failure, pulmonary embolism, and certain medications, as evident from the most recent study 1.
Possible Causes of Atrial Fibrillation with Rapid Ventricular Response
The possible causes of AF with a rapid ventricular response include:
- Hyperthyroidism, which increases cardiac sensitivity to catecholamines
- Acute infections or febrile illnesses that increase metabolic demands
- Stimulant use, including caffeine, alcohol, cocaine, or amphetamines
- Electrolyte abnormalities, particularly hypokalemia or hypomagnesemia
- Heart failure with increased sympathetic tone
- Pulmonary embolism causing right heart strain
- Acute coronary syndromes
- Untreated obstructive sleep apnea
- Pericarditis
- Valvular heart disease, especially mitral valve disease
- Post-cardiac surgery states
- Certain medications, such as theophylline, beta-agonists, and some antidepressants
Management of Atrial Fibrillation with Rapid Ventricular Response
The management of AF with a rapid ventricular response typically involves rate control with beta-blockers, calcium channel blockers, or digoxin, while addressing the underlying cause, as recommended by the 2014 AHA/ACC/HRS guideline 1. The goals of therapy include prevention of thromboembolism and control of symptoms. Rate control can be achieved with:
- Beta-blockers, such as metoprolol 25-100mg twice daily
- Calcium channel blockers, such as diltiazem 30-120mg three to four times daily
- Digoxin, 0.125-0.25mg daily In hemodynamically unstable patients, immediate electrical cardioversion may be necessary. Anticoagulation should be considered based on stroke risk assessment using the CHA₂DS₂-VASc score to prevent thromboembolic complications.
From the FDA Drug Label
Flecainide acetate, like other antiarrhythmic agents, can cause new or worsened supraventricular or ventricular arrhythmias. Ventricular proarrhythmic effects range from an increase in frequency of PVCs to the development of more severe ventricular tachycardia, e.g., tachycardia that is more sustained or more resistant to conversion to sinus rhythm, with potentially fatal consequences. A paradoxical increase in the ventricular rate also may occur in patients with atrial fibrillation who receive flecainide acetate Concomitant negative chronotropic therapy such as digoxin or beta-blockers may lower the risk of this complication.
The possible causes of atrial fibrillation (AF) with a rapid ventricular response include:
- Paradoxical increase in ventricular rate due to flecainide acetate
- Ventricular proarrhythmic effects of flecainide acetate, including increased frequency of PVCs or development of more severe ventricular tachycardia
- Underlying cardiac disease, such as coronary artery disease or heart failure, which may contribute to the development of atrial fibrillation with a rapid ventricular response 2 2
From the Research
Possible Causes of Atrial Fibrillation (AF) with Rapid Ventricular Response
- Atrial fibrillation (AF) may occur in the context of a rapid ventricular rate/response (RVR), which can lead to complications such as hypoperfusion and cardiac ischemia 3
- Primary AF and secondary AF with RVR can be differentiated, with secondary AF often caused by underlying medical conditions such as heart failure, pneumonia, or sepsis 4
- The management of AF with RVR depends on the underlying cause, with rate or rhythm control pursued in hemodynamically stable patients, and emergent cardioversion indicated in hemodynamically unstable patients 3, 5
- Factors contributing to the adverse consequences of AF with rapid ventricular response include irregularity of ventricular response and variable changes in autonomic nervous system output, rather than just the rate itself 6
Underlying Medical Conditions
- Heart failure is a common underlying condition that can cause AF with RVR, with 12.8% of cases in one study attributed to heart failure 4
- Pneumonia and sepsis are also significant contributors, accounting for 11.7% and 8.4% of cases, respectively 4
- Other medical conditions, such as coronary heart disease, hypertension, and diabetes, can also increase the risk of developing AF with RVR 7
Treatment Options
- Rate control using beta blockers or calcium channel blockers is a common treatment approach for AF with RVR, with the goal of reducing symptoms and preventing complications 3, 6
- Verapamil, a calcium channel blocker, has been shown to be effective in converting AF to sinus rhythm in some cases, and may be a useful treatment option in the absence of antiarrhythmic drugs 7
- Digoxin, beta blockers, and calcium channel blockers can all be used to control the ventricular rate in AF, although their effectiveness may vary depending on the individual patient and the underlying cause of the AF 5, 6