What is the best treatment for atrial fibrillation (AFib) with rapid ventricular response (RVR) and chest pain?

From the Guidelines

The best treatment for atrial fibrillation with rapid ventricular response (AFib with RVR) and chest pain is immediate rate control with intravenous medications such as beta-blockers or calcium channel blockers, along with anticoagulation and evaluation for underlying causes of chest pain, as recommended by the 2024 ESC guidelines 1.

Initial Management

Initial management includes:

• Rate control with intravenous medications such as diltiazem (typical dose 0.25 mg/kg over 2 minutes) or metoprolol (5-15 mg IV in divided doses) to control heart rate and reduce symptoms 1
• Anticoagulation with heparin or low molecular weight heparin to prevent thromboembolism, as recommended by the 2024 ESC guidelines 1
• Evaluation of chest pain with ECG, cardiac enzymes, and possibly imaging to rule out acute coronary syndrome or other complications
• Oxygen administration if saturation is low

Long-term Management

Once stabilized, long-term management includes:

• Oral rate control medications (beta-blockers, calcium channel blockers) to control heart rate and reduce symptoms 1
• Rhythm control strategies (antiarrhythmics, cardioversion, or ablation) to reduce symptoms and morbidity, as recommended by the 2024 ESC guidelines 1
• Continued anticoagulation based on stroke risk assessment using the CHA₂DS₂-VASc score, as recommended by the 2024 ESC guidelines 1 This approach addresses both the immediate symptoms and underlying arrhythmia while preventing complications like stroke or heart failure. The chest pain component is particularly concerning as it may indicate myocardial ischemia due to rapid heart rate or concurrent coronary artery disease, which is why comprehensive cardiac evaluation is essential.

Key Considerations

• The 2024 ESC guidelines recommend a patient-centered approach to AF management, including shared decision-making and a multidisciplinary team 1
• The guidelines also emphasize the importance of comorbidity and risk factor management, as well as education for patients, family members, caregivers, and healthcare professionals 1
• The choice of anticoagulant should be based on the patient's individual risk of thromboembolism and bleeding, with DOACs preferred over VKAs in most cases 1

From the FDA Drug Label

Diltiazem Hydrochloride Injection or Diltiazem Hydrochloride for Injection are indicated for the following: Atrial Fibrillation or Atrial Flutter Temporary control of rapid ventricular rate in atrial fibrillation or atrial flutter The use of diltiazem hydrochloride injection or diltiazem hydrochloride for injection should be undertaken with caution when the patient is compromised hemodynamically or is taking other drugs that decrease any or all of the following: peripheral resistance, myocardial filling, myocardial contractility, or electrical impulse propagation in the myocardium For either indication and particularly when employing continuous intravenous infusion, the setting should include continuous monitoring of the ECG and frequent measurement of blood pressure. A defibrillator and emergency equipment should be readily available

The best treatment for atrial fibrillation (AFib) with rapid ventricular response (RVR) and chest pain is not explicitly stated in the label. However, diltiazem (IV) can be used for temporary control of rapid ventricular rate in atrial fibrillation or atrial flutter.

• Key considerations for treatment include:
  • Continuous monitoring of the ECG and frequent measurement of blood pressure
  • Having a defibrillator and emergency equipment readily available
  • Using the medication with caution in patients who are compromised hemodynamically 2

From the Research

Treatment Options for Atrial Fibrillation with Rapid Ventricular Response and Chest Pain

• The treatment for atrial fibrillation (AFib) with rapid ventricular response (RVR) and chest pain typically involves rate control or rhythm control, with the goal of reducing symptoms and preventing complications 3.
• Rate control can be achieved using medications such as beta blockers (e.g., metoprolol) or calcium channel blockers (e.g., diltiazem, verapamil) 4, 5, 6.
• A study comparing metoprolol and diltiazem for AFib with RVR found that metoprolol was associated with a lower risk of adverse events, including hypotension and bradycardia 5.
• Another study found that weight-based metoprolol dosing may be effective for rate control in AFib with RVR, but further research is needed to confirm this 6.
• Verapamil, a calcium channel blocker, has also been shown to be effective in converting AFib to sinus rhythm in some cases, and may be considered as an alternative to other medications 7.

Medication-Specific Considerations

• Diltiazem has been shown to be safe and effective for rate control in AFib with RVR when used according to strict protocols 4.
• Metoprolol may be associated with a lower risk of adverse events compared to diltiazem, but further research is needed to confirm this 5.
• Verapamil may be considered as an alternative to other medications for converting AFib to sinus rhythm, but its use should be carefully monitored due to the risk of adverse events 7.

Clinical Decision-Making

• The choice of treatment for AFib with RVR and chest pain should be individualized based on patient-specific factors, including medical history, symptoms, and hemodynamic stability 3.
• Clinicians should carefully consider the potential benefits and risks of each medication, including the risk of adverse events, and monitor patients closely during treatment 4, 5, 6, 7.