Rapid Ventricular Rate Management

Definition and Classification

The American College of Cardiology defines ventricular tachycardia (VT) as three or more consecutive complexes originating from the ventricles at a rate greater than 100 beats per minute 4, 5
For atrial fibrillation (AF), adequate rate control is generally defined as 60-80 beats per minute at rest and 90-115 beats per minute during moderate exercise, according to the American College of Cardiology 1, 6
The American College of Cardiology recommends that adequate control in the AFFIRM trial be defined as an average heart rate up to 80 beats per minute at rest and either an average rate up to 100 beats per minute over at least 18-hour Holter monitoring or a maximum heart rate of 110 beats per minute during a 6-minute walk test 1, 6
The American College of Cardiology defines rate control in the RACE trial as less than 100 beats per minute at rest 1, 6

Heart rates <150 beats per minute are unlikely to cause symptoms of instability unless there is impaired ventricular function, as stated by the American Heart Association 2, 3
Sustained, uncontrolled tachycardia may lead to deterioration of ventricular function (tachycardia-related cardiomyopathy), according to the American College of Cardiology 1, 6
In patients with AF, rapid ventricular rates can cause inadequate time for ventricular filling, rate-related ischemia, and impaired hemodynamics, as reported by the American College of Cardiology 1, 6

Patients who are symptomatic with rapid ventricular rates during AF require prompt medical management, according to the American College of Cardiology 1, 6
The American College of Cardiology recommends cardioversion if symptomatic hypotension, angina, or heart failure is present 1, 6
When cardiac function is poor, cardiac output can be dependent on a rapid heart rate, so "normalizing" the heart rate can sometimes be detrimental, as stated by the American Heart Association 2
For hemodynamically unstable VT, synchronized cardioversion is recommended regardless of the duration, according to the American College of Cardiology 5

It may be useful to evaluate heart rate response to submaximal or maximal exercise or monitor rate over an extended period (e.g., 24-hour Holter recording), as suggested by the American College of Cardiology 1, 6
Rate variability during AF provides information about autonomic nervous system status that may have independent prognostic implications, according to the American College of Cardiology 1, 6

Rapid heart rates may be a physiological response to stressors such as fever, anemia, or hypotension/shock rather than a primary arrhythmia, as stated by the American Heart Association 2, 3
In patients with poor ventricular function, even rates <150 beats per minute can cause symptoms and hemodynamic compromise, according to the American Heart Association 2, 3
When treating rapid ventricular rates, always assess for and address underlying causes rather than simply targeting the heart rate, as recommended by the American College of Cardiology 3