How to manage atrial fibrillation (Afib) with rapid ventricular response (RVR) in a patient with heart failure?

Management of Atrial Fibrillation with Rapid Ventricular Response in Heart Failure

For patients with atrial fibrillation (AF) with rapid ventricular response (RVR) and heart failure, intravenous digoxin or amiodarone is recommended as first-line therapy for acute rate control, while beta blockers should be used cautiously in those with decompensated heart failure. 1

Initial Assessment and Management

• Determine if the patient has heart failure with preserved ejection fraction (HFpEF) or reduced ejection fraction (HFrEF), as this affects medication selection 1
• Assess for hemodynamic stability, as unstable patients may require immediate electrical cardioversion 2
• Evaluate for potential reversible causes of AF with RVR, including electrolyte abnormalities and thyroid dysfunction 3

Acute Rate Control Strategy

For Compensated Heart Failure:

• For HFpEF patients:

  • Beta blockers or nondihydropyridine calcium channel antagonists (diltiazem, verapamil) are recommended as first-line therapy 1
  • A combination of digoxin and a beta blocker is reasonable to control both resting and exercise heart rate 1, 4

• For HFrEF patients:

  • Beta blockers are preferred first-line agents for rate control 4
  • Use beta blockers with caution in patients with overt congestion or hypotension 1

For Decompensated Heart Failure:

• Intravenous digoxin or amiodarone is recommended for acute rate control 1
• Avoid intravenous nondihydropyridine calcium channel antagonists, intravenous beta blockers, and dronedarone as they may worsen hemodynamic compromise 1
• Recent evidence suggests diltiazem may be considered in select cases of AF with RVR and heart failure when other agents fail, though caution is still warranted 5, 6

Medication Dosing

• Digoxin:

  • Initial loading dose based on lean body weight and renal function, typically 0.25 mg daily for a 70 kg patient with normal renal function 7
  • Maintenance dose should be adjusted based on clinical response and serum levels 7

• Amiodarone:

  • Loading dose of approximately 1000 mg over the first 24 hours 8
  • Maintenance infusion rate of 0.5 mg/min (720 mg per 24 hours) 8
  • Must be delivered by volumetric infusion pump, preferably through a central venous catheter 8

Long-term Management

• For patients with persistent symptoms despite rate control, a rhythm control strategy may be reasonable 1
• For patients with AF and RVR causing or suspected of causing tachycardia-induced cardiomyopathy, either AV nodal blockade or a rhythm-control strategy is reasonable 1
• Oral amiodarone may be considered when resting and exercise heart rate cannot be adequately controlled using other agents 1
• AV node ablation with ventricular pacing is reasonable when pharmacological therapy is insufficient or not tolerated 1

Heart Rate Targets

• Lenient rate control (resting heart rate <110 bpm) is an acceptable initial approach unless symptoms call for stricter control 4
• Assessment of heart rate control during exercise and adjustment of pharmacological treatment is useful in symptomatic patients during activity 1

Important Caveats

• AV node ablation should not be performed without a prior pharmacological trial to achieve ventricular rate control 1
• Digoxin alone is often ineffective for controlling ventricular rate during exercise or in states of high sympathetic tone 4, 2
• Recent studies suggest diltiazem may reduce heart rate more quickly than metoprolol in AF with RVR, but safety concerns remain in decompensated heart failure 5, 9, 10
• Always consider anticoagulation based on stroke risk factors regardless of rate control strategy 3, 4