What is the management of atrial fibrillation (Afib) with rapid ventricular response (RVR)?

From the Guidelines

Management of atrial fibrillation with rapid ventricular response (AFib with RVR) should prioritize controlling heart rate and preventing complications, with initial management including IV rate control medications such as metoprolol, diltiazem, or esmolol, as recommended by the 2024 ESC guidelines 1. The goal of treatment is to reduce symptoms, prevent morbidity, and improve quality of life. Key considerations include:

• Controlling heart rate to reduce symptoms and prevent complications
• Assessing anticoagulation needs using the CHA₂DS₂-VASc score, with direct oral anticoagulants (DOACs) like apixaban preferred for most patients with scores ≥2 1
• Considering rhythm control strategies for symptomatic patients, including antiarrhythmic drugs or elective cardioversion
• Transitioning to oral rate control medications after acute stabilization, such as metoprolol or diltiazem ER The 2024 ESC guidelines emphasize the importance of a patient-centered approach, with shared decision-making and a multidisciplinary team 1. In contrast, older guidelines, such as the 2010 ESC guidelines, may recommend different approaches to rate control, such as oral administration of beta-blockers or non-dihydropyridine calcium channel antagonists 1. However, the most recent and highest-quality evidence supports the use of IV rate control medications and DOACs as first-line treatments for AFib with RVR. The use of DOACs, such as apixaban, is preferred over vitamin K antagonists (VKAs) due to their improved safety and efficacy profile 1.

From the FDA Drug Label

Sotalol AF has been studied in patients with symptomatic AFIB/AFL in two principal studies, one in patients with primarily paroxysmal AFIB/AFL, the other in patients with primarily chronic AFIB. Sotalol AF was shown to prolong the time to the first symptomatic, ECG-documented recurrence of AFIB/AFL, as well as to reduce the risk of such recurrence at both 6 and 12 months. The recommended initial dose of Sotalol AF is 80 mg and is initiated as shown in the dosing algorithm described below. Patients with atrial fibrillation should be anticoagulated according to usual medical practice.

The management of Atrial Fibrillation (AFib) with RVR (Rapid Ventricular Response) using Sotalol involves:

• Initiation of therapy: in a setting with continuous ECG monitoring and personnel trained in managing serious ventricular arrhythmias.
• Dosing: the recommended initial dose is 80 mg, with possible titration to 120 mg based on patient response and QT interval monitoring.
• Monitoring: patients should be monitored for QT interval prolongation, and the dose should be adjusted or discontinued if the QT interval exceeds 500 msec.
• Anticoagulation: patients with atrial fibrillation should be anticoagulated according to usual medical practice.
• Indications: Sotalol AF is indicated for the maintenance of normal sinus rhythm in patients with symptomatic AFIB/AFL who are currently in sinus rhythm 2. The use of Sotalol for AFib with RVR management should be individualized based on the patient's specific condition, renal function, and other factors, with careful monitoring for potential proarrhythmic effects 2, 2.

From the Research

Afib with RVR Management

• The management of atrial fibrillation (AF) with rapid ventricular response (RVR) involves controlling the ventricular rate to prevent hemodynamic consequences 3.
• 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.

Comparison of Metoprolol and Diltiazem

• Metoprolol was associated with a 26% lower risk of adverse events compared to diltiazem in patients with AF with RVR 4.
• Patients with higher initial heart rates faced higher rates of adverse events 4.
• There was no difference in rates of bradycardia or hypotension between metoprolol and diltiazem 4, 5, 6.
• IV diltiazem treatment was significantly more successful in rate control for AF with RVR than IV metoprolol, but also led to a significantly greater reduction in ventricular rate and an increased risk of hypotension 7.

Special Considerations

• In patients with heart failure with reduced ejection fraction (HFrEF), there was no difference in total adverse events between diltiazem and metoprolol, but the diltiazem group had a higher incidence of worsening heart failure symptoms 5.
• Cardioversion is the treatment of choice in all cases of AF with RVR when the clinical condition is unstable or hemodynamically compromised 3.
• Radiofrequency ablation of the AV node or anomalous tract may be considered in refractory or high-risk subjects as a last resort 3.