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

From the Guidelines

Management of atrial fibrillation with rapid ventricular response requires prompt intervention with rate control therapy, using beta-blockers, diltiazem, verapamil, or digoxin as first-choice drugs to control heart rate and reduce symptoms, as recommended by the 2024 ESC guidelines 1. The initial management should focus on rate control with intravenous beta-blockers like metoprolol or calcium channel blockers such as diltiazem. For hemodynamically unstable patients, immediate synchronized cardioversion is indicated. Once stabilized, oral medications for long-term rate control include metoprolol, diltiazem, or digoxin for patients with heart failure. Some key points to consider in the management of atrial fibrillation include:

• Anticoagulation therapy should be initiated based on stroke risk assessment using the CHA₂DS₂-VASc score, with options including warfarin or direct oral anticoagulants like apixaban, rivaroxaban, or dabigatran, as recommended by the 2024 ESC guidelines 1.
• For rhythm control in selected patients, antiarrhythmic medications such as amiodarone, flecainide, or propafenone may be considered, or referral for catheter ablation if medication therapy fails.
• The dual approach of rate control and anticoagulation works because rate control prevents tachycardia-induced cardiomyopathy and reduces symptoms, while anticoagulation prevents thromboembolic complications resulting from blood stasis in the atria during fibrillation. The 2024 ESC guidelines provide a comprehensive approach to the management of atrial fibrillation, emphasizing the importance of rate control, anticoagulation, and rhythm control in selected patients 1. In addition to the 2024 ESC guidelines, other studies have also emphasized the importance of rate control and anticoagulation in the management of atrial fibrillation, such as the 2010 American Heart Association guidelines 1. However, the 2024 ESC guidelines provide the most recent and highest quality evidence for the management of atrial fibrillation, and should be prioritized in clinical practice. Some of the key recommendations from the 2024 ESC guidelines include:
• Rate control therapy is recommended in patients with AF, as initial therapy in the acute setting, an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and reduce symptoms.
• Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs in patients with AF and LVEF >40% to control heart rate and reduce symptoms.
• Atrioventricular node ablation combined with cardiac resynchronization therapy should be considered in severely symptomatic patients with permanent AF and at least one hospitalization for HF to reduce symptoms, physical limitations, recurrent HF hospitalization, and mortality.

From the Research

Management Strategies

• The management of atrial fibrillation (AF) with rapid ventricular response (RVR) involves evaluating the entire clinical context, including cardiovascular status and associated noncardiac clinical disorders 2.
• Intravenous beta blockers and calcium channel blockers are equally effective in rapidly controlling the ventricular rate in acute AF in selected individuals 2.
• The addition of digoxin to the regimen can cause a favorable outcome, but digoxin as a single agent is generally inefficacious in slowing the ventricular rate in acute AF 2.

Treatment Options

• For hemodynamically unstable patients, emergent cardioversion is indicated 3.
• For hemodynamically stable patients, rate or rhythm control should be pursued 3.
• Beta blockers or calcium channel blockers can be used for rate control in patients with AF and RVR who do not undergo cardioversion 3, 4.
• Diltiazem may achieve rate control faster than metoprolol, though both agents seem safe and effective 4.

Special Considerations

• In patients with heart failure with reduced ejection fraction (HFrEF), non-dihydropyridine calcium channel blockers should be avoided due to their potential negative inotropic effects 5.
• However, a study found that the incidence of adverse effects was similar between patients treated with IV diltiazem and metoprolol, although the diltiazem group had a higher incidence of worsening heart failure symptoms 5.
• Anticoagulation is an important component of management, and several tools (e.g., CHA2DS2-VASc) are available to assist with this decision 3.
• Direct oral anticoagulants are the first-line medication class for anticoagulation 3.

Disposition and Risk Assessment

• Disposition can be challenging, and several risk assessment tools (e.g., RED-AF, AFFORD, and the AFTER scores) are available to assist with disposition decisions 3.
• Understanding the recent updates in the literature concerning AF with RVR can assist emergency clinicians in the care of these patients 3.