What is the best management approach for a patient with rheumatic heart disease (RHD) presenting with atrial fibrillation (AF) in rapid ventricular response (RVR) and tachycardia?

Management of Rheumatic Heart Disease with Atrial Fibrillation in Rapid Ventricular Response (HR 200)

Immediate Hemodynamic Assessment and Stabilization

For a patient with rheumatic heart disease presenting with AF in RVR at heart rate 200 bpm, immediate assessment of hemodynamic stability is critical, and if the patient shows severe hemodynamic compromise, ongoing ischemia, or signs of decompensation, urgent direct-current cardioversion is required. 1

• If the patient is hemodynamically stable, proceed with pharmacological rate control as the initial strategy 2, 1
• Obtain a 12-lead ECG immediately to confirm AF diagnosis and exclude pre-excitation syndromes (Wolff-Parkinson-White), which would contraindicate AV nodal blocking agents 1

Pharmacological Rate Control Strategy

For Patients with Preserved Ejection Fraction or Compensated Heart Failure

Intravenous diltiazem or metoprolol should be administered as first-line therapy, targeting a heart rate <110 bpm at rest. 1

• IV diltiazem is likely superior to metoprolol for achieving faster rate control, though both agents are safe and effective 3
• In the absence of pre-excitation, IV beta-blocker administration (or nondihydropyridine calcium channel antagonist) is recommended to slow ventricular response acutely, with caution in patients with overt congestion or hypotension 2
• For emergency use, IV diltiazem or esmolol are preferred due to their rapid onset of action 4, 5

For Patients with Decompensated Heart Failure or Reduced LVEF

If the patient has decompensated heart failure or reduced left ventricular ejection fraction, use intravenous digoxin or amiodarone for acute rate control instead of beta-blockers or calcium channel blockers. 2, 1

• IV nondihydropyridine calcium channel antagonists, IV beta-blockers, and dronedarone should NOT be administered to patients with decompensated HF 2
• In the absence of pre-excitation, IV digoxin or amiodarone is recommended to control heart rate acutely in patients with HF 2

Special Considerations for Rheumatic Heart Disease

Valvular Status and Anticoagulation

Patients with rheumatic heart disease typically have valvular involvement (most commonly mitral stenosis), which classifies this as valvular AF requiring warfarin anticoagulation rather than direct oral anticoagulants. 6

• Calculate CHA₂DS₂-VASc score immediately, though rheumatic heart disease with AF generally mandates anticoagulation regardless of score 6
• For AF duration >48 hours or unknown duration, anticoagulation for at least 3-4 weeks is required before and after cardioversion if rhythm control is pursued 1

Combination Therapy if Single Agent Fails

If monotherapy with a beta-blocker or calcium channel blocker fails to achieve adequate rate control, combination therapy with digoxin plus a beta-blocker (or nondihydropyridine calcium channel antagonist) is reasonable. 2, 1

• Digoxin is effective for controlling resting heart rate but not exercise heart rate in patients with HF with reduced EF 2
• Oral amiodarone may be considered only when resting and exercise heart rate cannot be adequately controlled using other agents alone or in combination 2

Transition to Oral Rate Control

Once acute rate control is achieved, transition immediately to oral diltiazem 120-360 mg daily (extended release) or oral metoprolol tartrate 25-200 mg twice daily for sustained rate control. 6

• Typical starting doses are diltiazem 120-180 mg daily extended release 6
• Alternatively, metoprolol succinate 50-400 mg daily can be used 6

Assessment for Tachycardia-Induced Cardiomyopathy

For patients with AF and rapid ventricular response causing or suspected of causing tachycardia-induced cardiomyopathy, it is reasonable to achieve rate control by either AV nodal blockade or a rhythm-control strategy. 2

• If tachycardia-induced cardiomyopathy is confirmed or suspected, AV node ablation with ventricular pacing is reasonable when pharmacological therapy is insufficient or not tolerated 2, 6
• AV node ablation should NOT be performed without a pharmacological trial to achieve ventricular rate control first 2, 1

Rhythm Control Considerations

For patients with chronic HF who remain symptomatic from AF despite a rate-control strategy, it is reasonable to use a rhythm-control strategy. 2

• Younger patients, those with recent-onset AF, or highly symptomatic patients may benefit more from rhythm control 6
• If pursuing rhythm control, options include electrical cardioversion or pharmacological cardioversion with Class IC or Class III antiarrhythmics 6

Monitoring and Follow-Up

Arrange close outpatient follow-up within 1-2 weeks to assess response to therapy, and ensure appropriate monitoring for anticoagulation (INR for warfarin). 6

• Assessment of heart rate control during exercise and adjustment of pharmacological treatment to keep the rate in the physiological range is useful in symptomatic patients during activity 2
• Adequate ventricular rate control should be evaluated by either 24-hour Holter monitoring or submaximal stress test 5

Critical Pitfalls to Avoid

• Never use AV nodal blocking agents (beta-blockers, calcium channel blockers, digoxin) if pre-excitation (WPW) is present, as they can accelerate conduction through the accessory pathway and precipitate ventricular fibrillation 1
• Avoid IV calcium channel blockers or beta-blockers if decompensated heart failure is present, as this may cause harm 6, 1
• Do not use digoxin as monotherapy for rate control in active patients, as it is only effective for resting heart rate control 7, 8