What is the treatment for atrial fibrillation with rapid ventricular rate, including medication doses?

Treatment of Atrial Fibrillation with Rapid Ventricular Rate

For hemodynamically stable patients with atrial fibrillation and rapid ventricular response, intravenous beta blockers (metoprolol 2.5-5 mg IV bolus) or nondihydropyridine calcium channel blockers (diltiazem 0.25 mg/kg IV) are first-line agents, while hemodynamically unstable patients require immediate electrical cardioversion. 1

Acute Management Algorithm

Step 1: Assess Hemodynamic Stability

Unstable patients (hypotension, acute heart failure, ongoing chest pain, altered mental status):

• Immediate electrical cardioversion is indicated 1
• Do not attempt pharmacologic rate control in unstable patients 1

Stable patients proceed to pharmacologic rate control:

Step 2: Rule Out Pre-excitation (Wolff-Parkinson-White)

• If wide-complex irregular rhythm or known WPW: avoid all AV nodal blocking agents (beta blockers, calcium channel blockers, digoxin, amiodarone) as these can paradoxically increase ventricular response and precipitate ventricular fibrillation 1, 2
• Use IV procainamide instead for pre-excited AF 2

Step 3: Select Initial Rate Control Agent Based on Clinical Context

For patients WITHOUT heart failure:

Beta blockers (Class I, Level B): 1

• Metoprolol tartrate: 2.5-5 mg IV bolus over 2 minutes; may repeat up to 3 doses 1
• Esmolol: 500 mcg/kg IV bolus over 1 minute, then 50-300 mcg/kg/min infusion 1
• Propranolol: 1 mg IV over 1 minute, up to 3 doses at 2-minute intervals 1

OR Nondihydropyridine calcium channel blockers (Class I, Level B): 1

• Diltiazem: 0.25 mg/kg IV bolus over 2 minutes, then 5-15 mg/hour infusion 1
  • Lower doses (≤0.2 mg/kg) are equally effective and cause less hypotension than standard dosing 3
• Verapamil: 0.075-0.15 mg/kg IV bolus over 2 minutes 1

For patients WITH decompensated heart failure:

• Avoid nondihydropyridine calcium channel blockers (Class III: Harm) 1
• Digoxin: 0.25 mg IV every 2 hours, up to 1.5 mg over 24 hours 1
• Amiodarone (Class IIa, Level B): 150 mg IV over 10 minutes, then 1 mg/min infusion for 6 hours, then 0.5 mg/min 1
  • Note: Amiodarone may convert AF to sinus rhythm, which should be considered before administration 1

For patients WITH compensated heart failure and preserved ejection fraction:

• Beta blockers or nondihydropyridine calcium channel blockers can be used cautiously 1

Step 4: Rate Control Targets

Strict rate control (Class IIa, Level B):

• Resting heart rate <80 bpm 1
• Exercise heart rate 90-115 bpm 1, 4
• Recommended for symptomatic patients 1

Lenient rate control (Class IIb, Level B):

• Resting heart rate <110 bpm 1, 5
• May be reasonable for asymptomatic patients with preserved LV function 1, 5

Step 5: Transition to Oral Maintenance Therapy

Beta blockers: 1, 5

• Metoprolol tartrate: 25-100 mg twice daily 1, 5
• Metoprolol succinate (XL): 50-400 mg once daily 1
• Atenolol: 25-100 mg once daily 1
• Carvedilol: 3.125-25 mg twice daily 1

Calcium channel blockers: 1

• Diltiazem ER: 120-360 mg once daily 1
• Verapamil ER: 180-480 mg once daily 1

Digoxin: 1, 6

• 0.125-0.25 mg once daily 1
• Particularly useful in heart failure patients 1
• Less effective as monotherapy for rate control, especially during exercise 1, 7
• Best used in combination with beta blockers or as add-on therapy 7

Critical Pitfalls to Avoid

Do not use in pre-excitation: Digoxin, calcium channel blockers, beta blockers, and amiodarone are contraindicated in AF with WPW (Class III: Harm) 1

Do not use in decompensated heart failure: Nondihydropyridine calcium channel blockers and IV beta blockers should not be given to patients with overt decompensated heart failure (Class III: Harm) 1

Combination therapy: If single-agent therapy fails to achieve rate control, combination therapy (e.g., beta blocker plus digoxin) is reasonable (Class IIa, Level B) 1, 2

Digoxin limitations: Digoxin alone is generally ineffective for acute rate control and should not be used as monotherapy in the acute setting (Class IIb) 1, 8, 2

Monitor for bradycardia: All rate control agents can cause excessive bradycardia requiring dose adjustment or permanent pacing 1

Special Populations

Post-cardiac surgery: Beta blockers are recommended unless contraindicated (Class I, Level A) 1

Hyperthyroidism or high adrenergic states: Beta blockers are preferred 1, 2

Chronic obstructive pulmonary disease/asthma: Nondihydropyridine calcium channel blockers are preferred over beta blockers 2

Pregnancy: Beta blockers are the preferred agents for acute rate control 2