From the Guidelines
Management of atrial fibrillation with rapid ventricular response (AFib with RVR) in the setting of pulmonary embolism (PE) should prioritize rate control using intravenous beta-blockers or calcium channel blockers, while also initiating anticoagulation for PE with heparin or low molecular weight heparin, as recommended by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.
Key Considerations
- For rate control, intravenous beta-blockers like metoprolol (5-15 mg IV) or calcium channel blockers such as diltiazem (0.25 mg/kg IV over 2 minutes, followed by infusion if needed) are typically first-line options, but beta-blockers should be used cautiously in PE patients with hemodynamic instability as they may worsen hypotension 1.
- Amiodarone (150 mg IV over 10 minutes, followed by infusion) may be preferred in unstable patients as it has less negative inotropic effect, as suggested by the 2014 AHA/ACC/HRS guideline 1.
- Anticoagulation for PE must be initiated promptly with heparin (80 units/kg bolus followed by 18 units/kg/hr infusion) or low molecular weight heparin like enoxaparin (1 mg/kg twice daily), as recommended by the European Society of Cardiology guidelines on the diagnosis and management of acute pulmonary embolism 1.
- Hemodynamically unstable PE patients may require thrombolysis with alteplase (100 mg IV over 2 hours), as indicated by the European Society of Cardiology guidelines 1.
Additional Supportive Measures
- Oxygen supplementation, fluid management, and vasopressor support may be necessary depending on the patient's condition.
- The AFib with RVR in PE occurs because right heart strain from the clot burden triggers atrial arrhythmias, and treating the underlying PE often helps resolve the arrhythmia as right heart pressures normalize.
Prioritization of Outcomes
- The management strategy should prioritize morbidity, mortality, and quality of life outcomes, focusing on stabilizing the patient and addressing both AFib with RVR and PE simultaneously.
From the Research
Afib with RVR in PE Management
- Atrial fibrillation (AF) with rapid ventricular response (RVR) is a common tachyarrhythmia that requires hospitalization and can lead to complications such as hypoperfusion and cardiac ischemia 2.
- The management of AF with RVR involves differentiating primary and secondary AF with RVR, evaluating hemodynamic stability, and using troponin to determine the risk of adverse outcomes 2.
- Emergent cardioversion is indicated in hemodynamically unstable patients, while rate or rhythm control should be pursued in hemodynamically stable patients 2, 3.
- Rate control using beta blockers or calcium channel blockers should be pursued in those with AF with RVR who do not undergo cardioversion 2, 4, 3, 5.
- Beta blockers, such as metoprolol, are effective in maintaining sinus rhythm and controlling the ventricular rate during atrial fibrillation, and may be considered as first-line agents in the management of patients with AF 4.
- However, recent studies have questioned the use of beta blockers as a preferred rate-control therapy in patients with atrial fibrillation 6.
- Calcium channel blockers, such as diltiazem, may achieve rate control faster than beta blockers, such as metoprolol, and both agents seem safe and effective 5.
- Anticoagulation is an important component of management, and several tools are available to assist with this decision, including the CHA2DS2-VASc score 2.
- Disposition can be challenging, and several risk assessment tools are available to assist with disposition decisions, including the RED-AF, AFFORD, and AFTER scores 2.