What is the treatment for atrial fibrillation (Afib) with rapid ventricular response (RVR) and hypotension?

From the Guidelines

Treatment for atrial fibrillation with rapid ventricular response (AFib with RVR) causing hypotension requires immediate intervention to stabilize the patient, with the first-line treatment being immediate synchronized cardioversion at 120-200 joules for hemodynamically unstable patients with hypotension. If the patient is less critically unstable, intravenous rate control medications can be used, including diltiazem (initial bolus of 0.25 mg/kg over 2 minutes, followed by infusion at 5-15 mg/hour), esmolol (loading dose of 500 mcg/kg over 1 minute, then 50-200 mcg/kg/min), or metoprolol (5 mg IV over 2-5 minutes, may repeat up to 3 doses) 1. Concurrent volume resuscitation with normal saline boluses (500-1000 mL) should be administered if the patient is hypovolemic.

• Key considerations include:
  • The need for immediate intervention to stabilize the patient
  • The use of synchronized cardioversion for hemodynamically unstable patients
  • The selection of appropriate rate control medications based on patient factors, such as heart failure or hypotension
  • The importance of treating underlying causes, such as sepsis, pulmonary embolism, or thyroid disorders
• The goal of treatment is to reduce heart rate to less than 100 beats per minute while improving blood pressure above 90/60 mmHg, which can be achieved through the use of rate control medications and volume resuscitation, as supported by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.
• Amiodarone (150 mg IV over 10 minutes, followed by 1 mg/min for 6 hours) can be considered for patients with heart failure or when other agents fail, as recommended in the guidelines 1.
• It is essential to note that the treatment approach may vary depending on the underlying cause of AFib with RVR and hypotension, and the patient's overall clinical condition, emphasizing the need for individualized care and careful consideration of the most recent and highest quality evidence, such as the 2014 AHA/ACC/HRS guideline 1.

From the FDA Drug Label

Verapamil Hydrochloride Injection, USP is indicated for the following: • Temporary control of rapid ventricular rate in atrial flutter or atrial fibrillation except when the atrial flutter and/or atrial fibrillation are associated with accessory bypass tracts (Wolff-Parkinson-White (W-P-W) and Lown-Ganong-Levine (L-G-L) syndromes)

Because a small fraction (<1%) of patients treated with verapamil hydrochloride respond with life-threatening adverse responses (rapid ventricular rate in atrial flutter/fibrillation, and an accessory bypass tract, marked hypotension, or extreme bradycardia/asystole − see CONTRAINDICATIONS and WARNINGS), the initial use of verapamil hydrochloride injection should, if possible, be in a treatment setting with monitoring and resuscitation facilities, including D.C.-cardioversion capability

The treatment for atrial fibrillation (Afib) with rapid ventricular response (RVR) and hypotension may involve the use of verapamil or amiodarone.

• Verapamil can be used for temporary control of rapid ventricular rate in atrial flutter or atrial fibrillation, but it should be used with caution in patients with hypotension.
• Amiodarone can be used to suppress life-threatening arrhythmias, but the initial dose and infusion rate should be carefully monitored to avoid hypotension. It is essential to monitor patients closely and have resuscitation facilities available when using these medications, especially in patients with hypotension 2.

From the Research

Treatment for Atrial Fibrillation with Rapid Ventricular Response and Hypotension

• The treatment for atrial fibrillation (Afib) with rapid ventricular response (RVR) and hypotension involves immediate direct-current (DC) cardioversion 3, 4.
• Intravenous beta blockers, diltiazem, or verapamil may be administered to slow a very rapid ventricular rate in Afib 3, 4.
• Metoprolol and diltiazem are commonly used for rate control in Afib with RVR, with metoprolol associated with a lower risk of adverse events (AEs) compared to diltiazem 5.
• However, diltiazem may be more effective in achieving rate control, especially in patients with heart failure 6, 7.
• The choice of treatment should be based on individual patient characteristics, such as the presence of heart failure, and the potential risks and benefits of each medication 5, 7.

Medication Options

• Metoprolol: associated with a lower risk of AEs, but may not be as effective in achieving rate control 5.
• Diltiazem: may be more effective in achieving rate control, but has a higher risk of AEs 5.
• Verapamil: may be used as an alternative to diltiazem, but has similar effects on heart rate and blood pressure 3, 4.
• Beta blockers: may be used in combination with other medications to achieve rate control 3, 4.

Special Considerations

• Heart failure: diltiazem may be more effective in achieving rate control, but its use should be cautious due to potential negative inotropic effects 7.
• Hypotension: careful monitoring of blood pressure is necessary when using medications for rate control, especially in patients with hypotension 3, 4.