From the Guidelines
Management of atrial fibrillation with rapid ventricular response (AFib with RVR) in a patient with heart failure with reduced ejection fraction (HFrEF) should prioritize a rhythm-control strategy, with consideration of catheter ablation, as it may lead to an improvement in LV function and quality of life, as suggested by the 2019 European Heart Journal study 1.
Initial Management
For acute rate control, administer intravenous beta-blockers such as metoprolol 5mg IV every 5 minutes up to 3 doses or diltiazem 0.25 mg/kg IV over 2 minutes (if no significant systolic dysfunction) to achieve acute rate control, as recommended by the 2014 AHA/ACC/HRS guideline 1.
Long-term Management
For long-term management, oral beta-blockers (metoprolol succinate 25-200mg daily, carvedilol 3.125-25mg twice daily, or bisoprolol 2.5-10mg daily) are preferred as they improve mortality in HFrEF.
- Avoid non-dihydropyridine calcium channel blockers like diltiazem and verapamil for chronic management as they can worsen heart failure.
- Digoxin (0.125-0.25mg daily with dose adjustments based on renal function) can be added as a second agent if needed.
Rhythm Control
For rhythm control, consider amiodarone 400mg twice daily for 1-2 weeks, then 200mg daily, as it's safer in HFrEF than other antiarrhythmics, as suggested by the 2019 European Heart Journal study 1.
Anticoagulation
Anticoagulation is essential regardless of rhythm control strategy, with options including warfarin (target INR 2-3) or direct oral anticoagulants like apixaban 5mg twice daily.
Catheter Ablation
Consider catheter ablation for recurrent AFib, especially in younger patients with symptomatic AFib despite medical therapy, as it may lead to an improvement in LV function and quality of life, as suggested by the 2019 European Heart Journal study 1.
Heart Failure Therapy
Optimize heart failure therapy with ACE inhibitors/ARBs, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors. Some key points to consider:
- The management of patients with HFrEF and recurrent AF (>3 months) after an initial ablation procedure should be individually tailored based on previous clinical outcome, updated risk-benefit assessment, and patient choice, as suggested by the 2019 European Heart Journal study 1.
- A repeat ablation procedure is reasonable to maintain rhythm control and improve long-term outcome, especially in patients who have clinically benefited from previous catheter ablation, as suggested by the 2019 European Heart Journal study 1.
From the Research
Management of Atrial Fibrillation with Rapid Ventricular Response in Patients with Heart Failure with Reduced Ejection Fraction
- The management of atrial fibrillation (AFib) with rapid ventricular response (RVR) in patients with heart failure with reduced ejection fraction (HFrEF) is crucial to prevent complications such as hypoperfusion and cardiac ischemia 2.
- Rate control using beta blockers or calcium channel blockers is a recommended approach for patients with AFib and RVR who do not undergo cardioversion 2.
- Studies have compared the effectiveness of metoprolol and diltiazem in achieving rate control in patients with AFib and RVR, with results showing that both medications can be effective, but with some differences in safety outcomes 3, 4, 5.
- The use of non-dihydropyridine calcium channel blockers (non-DHP CCBs) such as diltiazem may be considered in patients with HFrEF, despite potential concerns about negative inotropic effects 3, 4, 5.
- Catheter ablation for AFib in patients with HFrEF has shown promise in improving survival, quality of life, and ventricular function, and reducing heart failure hospitalizations 6.
Comparison of Metoprolol and Diltiazem
- A study published in 2023 found that patients treated with metoprolol were equally able to reach the primary outcome of rate control as those treated with diltiazem, with no significant differences in hypotensive and bradycardic events 3.
- Another study published in 2019 found that intravenous push (IVP) diltiazem achieved similar rate control with no increase in adverse events when compared to IVP metoprolol 4.
- However, a study published in 2022 found that the diltiazem group had a higher incidence of worsening heart failure symptoms, despite similar overall adverse effects compared to the metoprolol group 5.
Anticoagulation and Disposition
- Anticoagulation is an important component of management for patients with AFib and RVR, with direct oral anticoagulants being the first-line medication class 2.
- Disposition decisions can be challenging, and several risk assessment tools are available to assist with disposition decisions, including the RED-AF, AFFORD, and AFTER scores 2.