Afib with rapid ventricular response

• Definition: atrial fibrillation with HR > 100–110/minute

• Patients may be unstable or stable with or without symptoms.

• ECG: to confirm the diagnosis and identify any ECG features of preexcitation.

• Assess for any underlying causes, e.g., sepsis, pulmonary embolism, hypovolemia

• Assess patients for hemodynamic compromise.

  • Unstable: See “Management of unstable tachycardia with a pulse.”

  • Stable: Treatment (rate or rhythm control) will depend on the duration of symptoms and any complications [5]

    • Onset > 48 hours: Rate control is preferred. [50][51]

    • Onset < 48 hours: Consider rate control or rhythm control (e.g., cardioversion). [50][52]

• All patients

  • Consider indications for anticoagulation (see “Anticoagulation in atrial fibrillation”). [5][53]

  • Identify and treat the underlying cause.

  • Identify and treat any complications.

Patients with unstable Afib should be treated with immediate cardioversion!

• IV agents are recommended in the acute setting; consider combination with oral medications. [5][54]

• Target resting heart rate: < 80/minute (HR < 110/minute may be acceptable in asymptomatic patients with no evidence of LV systolic dysfunction) [5]

• Choose from one of the following (first-line):

  • Beta blockers

    • Esmolol

    • Propranolol

    • Metoprolol

  • Nondihydropyridine calcium channel blockers (contraindicated in patients with decompensated heart failure or preexcitation)

    • Diltiazem

    • Verapamil

• Consider one of the following if the patient has contraindications to any of the above or refractory symptoms:

  • Digoxin

  • Amiodarone

• Hemodynamically unstable patients, ongoing myocardial ischemia, decompensated heart failure: Perform synchronized electrical cardioversion. [5][9]

• Stable patients: Consult cardiology to determine if rhythm control is appropriate (See “Rhythm control for atrial fibrillation”).

• Most patients should be started on anticoagulation prior to the procedure (see “Anticoagulation during cardioversion in atrial fibrillation”).

Avoid CCBs and beta blockers in decompensated heart failure.

• Management of Afib with preexcitation (e.g., WPW)

  • Avoid AV nodal blocking agents

  • See “Stable, wide-complex tachycardia” for the approach to diagnosis and management.

Avoid CCBs, digoxin, and adenosine in patients with preexcitation because of the risk of the arrhythmia converting to ventricular fibrillation