From the Guidelines
Oral medication for atrial fibrillation (AFib) with rapid ventricular response (RVR) is typically managed with beta blockers, nondihydropyridine calcium channel antagonists, or digoxin.
Common Oral Medications
- Beta blockers: such as metoprolol (25-100 mg twice a day, orally) 1 or propranolol (80-240 mg daily in divided doses, orally) 1
- Nondihydropyridine calcium channel antagonists: such as diltiazem (120-360 mg daily in divided doses, orally) 1 or verapamil (120-360 mg daily in divided doses, orally) 1
- Digoxin: (0.125-0.375 mg daily, orally) 1, particularly for patients with heart failure, left ventricular dysfunction, or sedentary individuals
Special Considerations
- Amiodarone may be considered when other measures are unsuccessful or contraindicated, with a dose of 200 mg daily, orally 1
- Combination therapy may be necessary to achieve rate control in both acute and chronic situations, but requires careful dose titration 1
- Nonpharmacological therapy, such as catheter-directed ablation of the AV node, may be considered when pharmacological measures fail 1
From the Research
Oral Medication for Atrial Fibrillation with Rapid Ventricular Response
- The studies 2, 3, 4, 5, 6 compared the effectiveness of different oral medications for atrial fibrillation (AF) with rapid ventricular response (RVR).
- The medications compared included diltiazem, metoprolol, and amiodarone.
Comparison of Diltiazem and Metoprolol
- A study 2 found that oral immediate-release diltiazem was associated with a lower rate of treatment failure compared to intravenous continuous infusion diltiazem in patients with AF with RVR.
- Another study 3 found that metoprolol was associated with a 26% lower risk of adverse events compared to diltiazem in patients with AF with RVR.
- A study 4 found no difference in sustained rate control between intravenous diltiazem and metoprolol in patients with AF with RVR.
Weight-Based Metoprolol
- A systematic review 6 found that only two studies compared a weight-based dosing strategy of intravenous metoprolol versus intravenous diltiazem for AF with RVR, and these studies were underpowered.
- The review suggested that further studies are needed to provide better guidance on the use of weight-based metoprolol in the treatment of AF with RVR.
Other Medications
- A study 5 compared the effectiveness of metoprolol, diltiazem, and amiodarone in the management of AF with RVR in the intensive care unit, and found that metoprolol had a lower failure rate than amiodarone and was superior to diltiazem in achieving rate control at 4 hours.