Rate Control in Atrial Fibrillation with Rapid Ventricular Response
First-Line Therapy Selection
- IV beta-blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response, according to the American Heart Association 1
Dosing Considerations for Diltiazem
- Continuous infusion of diltiazem (5-15 mg/hour) may be needed after initial bolus, as recommended by the American College of Cardiology 2
Special Populations and Considerations
- For patients with heart failure, the American College of Cardiology recommends digoxin and amiodarone as preferred agents for rate control, and beta blockers as preferred agents due to favorable effects on morbidity and mortality 1, 3
- Amiodarone should be considered for rate control when patient has systolic heart failure and beta blockers are contraindicated or ineffective, as suggested by the American Heart Association 4
- The American College of Cardiology also recommends considering amiodarone for rate control when other measures for rate control are unsuccessful or contraindicated 5
Important Cautions
- Both diltiazem and amiodarone should be avoided in patients with pre-excited atrial fibrillation (e.g., WPW syndrome) as they may cause paradoxical increase in ventricular response, according to the American Heart Association and the European Society of Cardiology 6, 7
- Amiodarone has potential for significant toxicity including pulmonary fibrosis, hepatic injury, and proarrhythmia with long-term use, as warned by the American Heart Association 8
- Diltiazem should be used with caution in patients with depressed ejection fraction due to negative inotropic effects, as advised by the American College of Cardiology 3
Implementation in Clinical Practice
- For hemodynamically unstable patients with AFib with RVR, immediate electrical cardioversion is recommended regardless of medication choice, according to the American Heart Association 1