From the Guidelines
Atrial fibrillation with rapid ventricular response (AFib with RVR) should be treated with a two-pronged approach focusing on rate control and eventual rhythm control, prioritizing the use of beta-blockers, diltiazem, verapamil, or digoxin as first-choice drugs for rate control, as recommended by the 2024 ESC guidelines 1.
Rate Control
For immediate rate control, intravenous medications like metoprolol, diltiazem, or esmolol can be administered in acute settings.
- Metoprolol (5-15 mg IV)
- Diltiazem (0.25 mg/kg IV over 2 minutes)
- Esmolol (500 mcg/kg IV bolus) For ongoing management, oral medications such as metoprolol, diltiazem, or propranolol are typically used.
- Metoprolol (25-100 mg twice daily)
- Diltiazem (120-360 mg daily in divided doses)
- Propranolol (10-40 mg three to four times daily)
Rhythm Control and Anticoagulation
Anticoagulation therapy is essential to prevent stroke, with options including warfarin, apixaban, rivaroxaban, or dabigatran.
- The choice depends on the patient's CHA₂DS₂-VASc score, with scores ≥2 generally requiring anticoagulation. For rhythm control, cardioversion (electrical or pharmacological with amiodarone, flecainide, or propafenone) may be considered. Long-term management should address underlying causes such as hypertension, sleep apnea, or thyroid disease. Beta-blockers and calcium channel blockers work by slowing conduction through the AV node, reducing ventricular rate, while anticoagulants prevent clot formation in the atria where blood flow is irregular, significantly reducing stroke risk, as supported by the 2006 ACC/AHA/ESC guidelines 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for Afib RVR
- Intravenous (IV) diltiazem and metoprolol are commonly used to achieve rate control for atrial fibrillation with rapid ventricular response (RVR) 2.
- Metoprolol was associated with a 26% lower risk of adverse events compared to diltiazem, with a total incidence of 10% and 19%, respectively 2.
- Patients with higher initial heart rates faced higher rates of adverse events, with a correlation coefficient of 0.11 (95% CI 0.03-0.19, p = 0.006) 2.
Efficacy and Safety of Diltiazem and Metoprolol
- A study found that prehospital administration of diltiazem for Afib with RVR is safe and effective when strict protocols are followed, with an overall adverse event rate of 11% and clinical improvement in 57% of patients 3.
- Another study compared the efficacy and safety of IV metoprolol and diltiazem for rate control in Afib with RVR, finding no difference in the achievement of rate control between the two medications 4.
- A retrospective chart review found no difference in sustained rate control between IV diltiazem and metoprolol, with rates of 87.5% and 78.9%, respectively (p = 0.45) 5.
Considerations for Patients with Congestive Heart Failure
- For patients with concomitant heart failure with reduced ejection fraction (HFrEF), the American Heart Association recommends avoiding non-dihydropyridine calcium channel blockers (CCB) due to their potential negative inotropic effects 6.
- A study found that in HFrEF patients with Afib, there was no difference in total adverse events between IV diltiazem and metoprolol, but the diltiazem group had a higher incidence of worsening heart failure symptoms (33% vs 15%, P = 0.019) 6.