How should I manage a hemodynamically stable patient with symptomatic atrial fibrillation with rapid ventricular response (heart rate ~120 bpm), shortness of breath, chest pain, known hypertension, and clear lung fields?

Management of Hemodynamically Stable AFib with RVR (HR ~120), Chest Pain, Dyspnea, and Hypertension

Initiate intravenous diltiazem (0.25 mg/kg over 2 minutes, followed by 5–15 mg/h infusion) or intravenous metoprolol (2.5–5 mg over 2 minutes, up to three doses) immediately for rate control, while simultaneously starting anticoagulation based on stroke risk assessment. 1

Immediate Assessment & Stabilization

Confirm the diagnosis with a 12-lead ECG to document atrial fibrillation, assess ventricular rate, and exclude Wolff-Parkinson-White syndrome (look for delta waves and short PR interval). 1, 2

Rule out hemodynamic instability by checking for hypotension (SBP <90 mmHg), altered mental status, acute pulmonary edema, or ongoing myocardial ischemia—any of these mandate immediate synchronized electrical cardioversion at ≥200 J without waiting for anticoagulation. 1, 2

Assess for reversible triggers including acute coronary syndrome (given chest pain), pulmonary embolism, hyperthyroidism, electrolyte abnormalities (especially hypokalemia and hypomagnesemia), sepsis, or acute alcohol intoxication—correcting these may terminate the arrhythmia. 1, 2

Rate Control Strategy

First-Line Intravenous Agents

Diltiazem achieves rate control faster than metoprolol and is the preferred agent when rapid control is needed. 3, 1

• Diltiazem dosing: 0.25 mg/kg IV bolus over 2 minutes (typically 20 mg for a 70-kg patient), followed by a second bolus of 0.35 mg/kg if needed after 15 minutes, then continuous infusion at 5–15 mg/h titrated to heart rate <110 bpm. 1, 2

• Metoprolol dosing: 2.5–5 mg IV over 2 minutes, repeat every 5 minutes up to three doses (maximum 15 mg total), then transition to oral metoprolol 25–100 mg twice daily. 1, 2

Both agents are equally effective and safe in patients with preserved ejection fraction (LVEF >40%). 1, 4, 3

Target Heart Rate

Aim for a lenient resting heart rate <110 bpm initially—this is non-inferior to strict control (<80 bpm) for clinical outcomes and causes fewer adverse effects. 1, 2

Reassess rate control during activity after the acute episode resolves, as many patients have inadequate control during exertion despite acceptable resting rates. 1

If Monotherapy Fails

Add digoxin (0.25 mg IV, repeat up to 1.5 mg cumulative in 24 hours) to the beta-blocker or calcium-channel blocker for synergistic rate control at rest and during exercise. 1, 2

Never use digoxin as monotherapy in acute AFib with RVR—it has a slow onset (hours) and is ineffective during sympathetic surges or exercise. 1, 4, 5

Critical Pitfall: Wolff-Parkinson-White Syndrome

If the ECG shows a wide QRS with a delta wave (pre-excitation), immediately stop all AV-nodal blockers (beta-blockers, calcium-channel blockers, digoxin, adenosine, amiodarone)—these can paradoxically accelerate ventricular rate and precipitate ventricular fibrillation. 1, 2

Use IV procainamide instead (loading dose 15 mg/kg over 30–60 minutes) and prepare for emergent electrical cardioversion if the patient becomes unstable. 1, 4

Anticoagulation Decision

Stroke Risk Assessment

Calculate the CHA₂DS₂-VASc score immediately:

• Congestive heart failure (1 point)
• Hypertension (1 point) ← your patient has this
• Age ≥75 years (2 points)
• Diabetes (1 point)
• Prior stroke/TIA/thromboembolism (2 points)
• Vascular disease (1 point)
• Age 65–74 years (1 point)
• Female sex (1 point) 1, 2

Initiate oral anticoagulation for all patients with a score ≥2 (men) or ≥3 (women) unless there is a clear contraindication (e.g., active bleeding, recent intracranial hemorrhage). 1, 2

Choice of Anticoagulant

Direct oral anticoagulants (apixaban, rivaroxaban, edoxaban, dabigatran) are preferred over warfarin due to lower intracranial hemorrhage risk and predictable pharmacokinetics. 1, 2

• Apixaban: 5 mg twice daily (or 2.5 mg twice daily if ≥2 of: age ≥80 years, weight ≤60 kg, creatinine ≥1.5 mg/dL) 2

If warfarin is used, target INR 2.0–3.0 with weekly monitoring during initiation and monthly once stable. 1, 2

Start anticoagulation immediately—do not wait for cardioversion decisions, as most strokes occur when anticoagulation is stopped or subtherapeutic. 1, 2

Addressing Chest Pain & Dyspnea

Obtain troponin to assess for acute coronary syndrome or myocardial injury—elevated troponin predicts adverse outcomes but does not mandate universal testing in low-risk patients with recurrent paroxysmal AFib similar to prior episodes. 6

Order a chest X-ray to exclude pulmonary edema (though lung sounds are clear, early interstitial edema may not be audible) or underlying lung disease. 2

Chest pain in AFib with RVR may represent:

• Demand ischemia from tachycardia (most common in this scenario)
• Acute coronary syndrome triggering AFib
• Pericarditis or myocarditis causing AFib 1, 6

If troponin is elevated or chest pain persists after rate control, pursue acute coronary syndrome workup with cardiology consultation. 6

Cardioversion Considerations

Elective cardioversion is NOT indicated in this hemodynamically stable patient—rate control with anticoagulation is equally effective as rhythm control for reducing mortality and cardiovascular events, with fewer adverse effects and hospitalizations. 1, 2

If cardioversion is later considered (e.g., persistent symptoms despite rate control, patient preference):

• For AFib duration >48 hours or unknown duration: provide therapeutic anticoagulation for ≥3 weeks before cardioversion and continue for ≥4 weeks after, OR perform transesophageal echocardiography to exclude left atrial thrombus. 1, 2
• For AFib duration <24 hours with CHA₂DS₂-VASc ≥2: still anticoagulate before cardioversion, as left atrial thrombus has been detected in up to 14% of short-duration AFib. 2

Special Considerations for Hypertension

Aggressive blood pressure control is essential—aim for <140/90 mmHg (stricter if tolerated) to reduce AFib recurrence and progression. 2

Beta-blockers or calcium-channel blockers used for rate control will simultaneously lower blood pressure, which is advantageous in this hypertensive patient. 1, 2

Monitoring & Disposition

Admit to telemetry monitoring for at least 24 hours to observe for rhythm changes, assess response to rate control, and monitor for complications (bradycardia, hypotension, recurrent RVR). 7

Obtain a transthoracic echocardiogram during admission to assess left atrial size, left ventricular function, valvular disease, and structural abnormalities. 1, 2

Check thyroid function, renal function, hepatic function, and electrolytes to identify reversible causes. 1, 2

Reassess CHA₂DS₂-VASc score at 6 months and annually to guide ongoing anticoagulation decisions. 2

Common Pitfalls to Avoid

Do not discontinue anticoagulation if sinus rhythm is restored—stroke risk is determined by the CHA₂DS₂-VASc score, not rhythm status; 72% of strokes in the AFFIRM trial occurred after anticoagulation was stopped or INR was subtherapeutic. 2

Do not use calcium-channel blockers if reduced ejection fraction (LVEF ≤40%) is discovered on echocardiogram—switch to beta-blockers and/or digoxin due to negative inotropic effects. 1, 2

Do not combine beta-blockers with diltiazem or verapamil without specialist supervision and ambulatory ECG monitoring, as this increases bradycardia risk. 2

Do not perform elective cardioversion without adequate anticoagulation (3–4 weeks therapeutic anticoagulation or TEE-guided exclusion of thrombus) when AFib duration exceeds 48 hours or is unknown. 1, 2