How to manage atrial fibrillation (AFib) with rapid ventricular response (RVR)?

From the Guidelines

Managing atrial fibrillation with rapid ventricular response (AFib with RVR) requires immediate rate control with intravenous medications like metoprolol, diltiazem, or amiodarone, followed by long-term management with oral medications, anticoagulation, and rhythm control strategies as needed. The most recent guidelines from the European Heart Journal 1 emphasize the importance of optimal treatment according to the AF-CARE pathway, which includes comorbidity and risk factor management, avoiding stroke and thromboembolism, reducing symptoms by rate and rhythm control, and evaluation and dynamic reassessment.

Key Management Strategies

• Rate control therapy: use beta-blockers, digoxin, or diltiazem/verapamil as initial therapy in the acute setting, as an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and symptoms 1.
• Anticoagulation: essential to prevent stroke, with options including warfarin, direct oral anticoagulants like apixaban, rivaroxaban, or dabigatran 1.
• Rhythm control: consider in all suitable AF patients, explicitly discussing with patients all potential benefits and risks of cardioversion, antiarrhythmic drugs, and catheter or surgical ablation to reduce symptoms and morbidity 1.

Specific Recommendations

• For acute management, intravenous medications like metoprolol (5-15 mg IV), diltiazem (0.25 mg/kg IV over 2 minutes), or amiodarone (150 mg IV over 10 minutes, followed by infusion) can rapidly slow the heart rate 1.
• Once stabilized, oral medications are typically prescribed for ongoing rate control, including beta-blockers (metoprolol 25-100 mg twice daily, carvedilol 3.125-25 mg twice daily), calcium channel blockers (diltiazem ER 120-540 mg daily, verapamil 120-480 mg daily), or digoxin (0.125-0.25 mg daily) 1.
• Addressing underlying causes such as hypertension, sleep apnea, or thyroid disorders is crucial for comprehensive management, as emphasized in the 2024 ESC guidelines 1.
• Lifestyle modifications including reducing alcohol intake, managing stress, and maintaining good hydration can help reduce AFib episodes and improve overall outcomes.

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 management of atrial fibrillation (AFib) with rapid ventricular response (RVR) can be done using digoxin, which slows the rapid ventricular response rate in a linear dose-response fashion from 0.25 to 0.75 mg/day 2.

• Key points:
  • Digoxin is used to slow the ventricular rate in patients with chronic AFib.
  • The dose of digoxin should be adjusted based on the patient's response.
  • Digoxin should not be used for the treatment of multifocal atrial tachycardia.

From the Research

Management of Atrial Fibrillation with Rapid Ventricular Response

• Atrial fibrillation (AFib) with rapid ventricular response (RVR) requires immediate attention to prevent complications such as hypoperfusion and cardiac ischemia 3
• The primary goal of management is to control the heart rate and prevent further complications

Rate Control Strategies

• Calcium channel blockers, such as diltiazem, and beta blockers, such as metoprolol, are commonly used for rate control in AFib with RVR 4, 5, 6, 7
• Diltiazem has been shown to be effective in controlling rapid ventricular response, with a recommended starting dose of 0.25 mg/kg over 2 minutes 4
• Low-dose diltiazem (≤ 0.2 mg/kg) may be as effective as the standard dose in controlling rapid AF and reduce the risk of hypotension 4
• Metoprolol is also effective in rate control, but may have a higher incidence of worsening heart failure symptoms in patients with heart failure with reduced ejection fraction (HFrEF) 6

Comparison of Diltiazem and Metoprolol

• A comprehensive umbrella review of systematic reviews and meta-analyses found that IV diltiazem was significantly more successful in rate control for AF with RVR than IV metoprolol 7
• IV diltiazem also led to a significantly greater reduction in ventricular rate, but was associated with a higher risk of hypotension 7
• The choice between diltiazem and metoprolol should be based on individual patient factors, such as comorbidities and clinical situation 5

Additional Considerations

• Hemodynamic stability should be assessed in patients with AFib and RVR, and emergent cardioversion should be considered in hemodynamically unstable patients 3
• Anticoagulation is an important component of management, and several tools are available to assist with this decision 3
• Disposition can be challenging, and several risk assessment tools are available to assist with disposition decisions 3