From the Guidelines
To treat acute atrial fibrillation (AFib) with rapid ventricular response (RVR), first stabilize the patient by controlling heart rate with beta-blockers, diltiazem, verapamil, or digoxin, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1. The choice of medication depends on the patient's left ventricular ejection fraction (LVEF) and other clinical factors.
- For patients with AF and LVEF >40%, beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs to control heart rate and reduce symptoms 1.
- For patients with AF and LVEF ≤40%, beta-blockers and/or digoxin are recommended to control heart rate and reduce symptoms 1. In hemodynamically unstable patients, immediate electrical cardioversion may be necessary, as indicated by previous guidelines 1. For stable patients, the goal is to control the ventricular rate using a beta blocker or nondihydropyridine calcium channel antagonist, as recommended by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1. It is also important to correct any underlying triggers such as electrolyte abnormalities, thyroid dysfunction, or infection, and to consider anticoagulation if AFib duration exceeds 48 hours or is unknown. The medications used for rate control work by blocking cardiac conduction pathways to slow ventricular response, while anticoagulation prevents thromboembolic complications associated with AFib. Overall, the treatment of acute AFib with RVR should prioritize controlling heart rate and reducing symptoms, while also considering the patient's underlying clinical factors and potential need for anticoagulation.
From the FDA Drug Label
In patients without structural heart disease, propafenone is indicated to prolong the time to recurrence of – paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms. Propafenone HCl should not be used to control ventricular rate during atrial fibrillation.
The treatment for acute atrial fibrillation (afib) with propafenone is not recommended for controlling ventricular rate.
- Propafenone is indicated for paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms.
- It is not recommended for use in controlling ventricular rate during atrial fibrillation. 2
From the Research
Treatment Options for Acute Atrial Fibrillation (AFib) and Rapid Ventricular Rates (RVR)
- Intravenous (i.v.) beta blockers and calcium channel blockers are equally effective in rapidly controlling the ventricular rate in acute AF in selected individuals 3.
- The addition of digoxin to the regimen causes a favorable outcome, however, digoxin as a single agent is generally inefficacious in slowing the ventricular rate in acute AF 3.
- Diltiazem likely achieves rate control faster than metoprolol, though both agents seem safe and effective 4.
- There is no difference in the achievement of rate control between IV metoprolol and diltiazem 5.
Special Considerations
- In patients with ventricular preexcitation syndrome associated with rapid ventricular rate due to AF, the drug of choice is i.v. procainamide 3.
- When the clinical condition is unstable or hemodynamically compromised, cardioversion is the treatment of choice in all cases of AF with rapid ventricular rate 3.
- Radiofrequency ablation of the AV node or anomalous tract may be considered in refractory or high-risk subjects as a last resort 3.
Management in Specific Settings
- In the emergency department setting, clinicians must consider the individual patient, clinical situation, and comorbidities when selecting a medication for rate control 4.
- In patients with acute decompensated heart failure, high-level evidence to inform clinical decision making regarding effective and safe management of AFRVR is lacking 6.
- Suboptimal use of rate control occurred in 47.0% of cases, with a concerning number of adverse events related to suboptimal use of rate control 7.