From the Guidelines
Atrial fibrillation (AFib) with rapid ventricular response (RVR) typically presents with symptoms including palpitations, shortness of breath, chest discomfort, dizziness, fatigue, and sometimes syncope, whereas AFib without RVR presents with similar irregular rhythm but at a controlled heart rate, resulting in milder or absent symptoms. The clinical presentation of AFib with RVR and without RVR can be distinguished based on the ventricular rate and the resulting symptoms.
- Symptoms of AFib with RVR include:
- Palpitations
- Shortness of breath
- Chest discomfort
- Dizziness
- Fatigue
- Syncope
- Physical examination of AFib with RVR reveals an irregularly irregular pulse and variable heart sounds.
- In contrast, AFib without RVR presents with similar irregular rhythm but at a controlled heart rate, resulting in milder or absent symptoms.
- Patients with AFib without RVR may be asymptomatic or experience only mild fatigue or reduced exercise tolerance. The difference in presentation stems from the ventricular rate; in AFib with RVR, the AV node conducts many atrial impulses to the ventricles, causing the rapid rate and more severe symptoms, as noted in the guidelines for the management of patients with atrial fibrillation 1. Management of AFib with RVR typically requires immediate rate control with medications like beta-blockers (metoprolol 5-15mg IV), calcium channel blockers (diltiazem 0.25mg/kg IV), or digoxin, followed by consideration of rhythm control strategies, as recommended in the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1. AFib without RVR may require less urgent intervention but still warrants assessment for stroke risk and appropriate anticoagulation based on CHA₂DS₂-VASc score, as emphasized in the guidelines for the management of patients with atrial fibrillation 1.
From the Research
Clinical Presentation of Atrial Fibrillation (AF) with Rapid Ventricular Response (RVR)
- Atrial fibrillation with rapid ventricular response is a common tachyarrhythmia that requires hospitalization due to increased morbidity and mortality from hemodynamic consequences 2.
- The clinical presentation of AF with RVR can lead to complications such as hypoperfusion and cardiac ischemia, making it essential for emergency physicians to diagnose and manage this condition promptly 3.
Differentiation between Primary and Secondary AF with RVR
- Differentiating primary and secondary AF with RVR is crucial in the emergency department (ED) assessment and management 3.
- Evaluating hemodynamic stability is vital in determining the appropriate treatment approach for patients with AF and RVR.
Treatment Approaches for AF with RVR
- For hemodynamically unstable patients, emergent cardioversion is indicated 3.
- In hemodynamically stable patients, rate or rhythm control should be pursued, with options including beta blockers or calcium channel blockers for rate control 3, 4, 5, 6.
- The choice of agent for rate control depends on individual patient factors, clinical situation, and comorbidities, with diltiazem and metoprolol being commonly used options 4, 6.
Comparison of Rate Control Efficacy between Beta-Blockers and Calcium Channel Blockers
- Studies have compared the efficacy of beta blockers and calcium channel blockers for rate control in patients with AF and RVR, with some findings suggesting that beta blockers may be more effective in rapidly reducing heart rate 5.
- However, the choice between these two medication classes ultimately depends on individual patient factors and clinical context 5, 6.