Atrial Fibrillation with RVR
Rapid ventricular response AF — rate control, rhythm control, and cardioversion
Overview
- Rapid ventricular response AF — rate control, rhythm control, and cardioversion
Protocol steps
- id: 1; title: Assess Stability; detail: Unstable (hypotension, AMS, chest pain, acute HF)? If unstable, proceed directly to synchronized cardioversion.; time: ; drugs: ; branch: true
- id: 2; title: Unstable — Synchronized Cardioversion; detail: Synchronized cardioversion 200J biphasic. Sedate if time permits (Etomidate 0.3mg/kg or Midazolam 2-5mg IV). May need repeat at higher energy.; time: ; drugs:
- id: 3; title: Stable — Rate Control; detail: Target HR <110 at rest. Choose agent based on cardiac function.; time: ; drugs: name: Metoprolol; dose: 5mg IV; interval: q5min x3 doses, then 25-50mg PO q6h; name: Diltiazem; dose: 0.25 mg/kg IV bolus over 2min; interval: then 5-15 mg/hr drip
- id: 4; title: Rhythm Control Consideration; detail: If onset <48 hours, cardioversion or antiarrhythmic reasonable without prolonged anticoagulation. If onset >48h or unknown, TEE first or anticoagulate 3 weeks.; time: ; drugs: ; branch: true
- id: 5; title: Amiodarone for Structural Heart Disease; detail: If reduced EF or structural heart disease, amiodarone preferred over other antiarrhythmics.; time: ; drugs: name: Amiodarone; dose: 150mg IV over 10min; interval: then 1mg/min x6h, then 0.5mg/min x18h
- id: 6; title: Anticoagulation — CHA2DS2-VASc; detail: Calculate CHA2DS2-VASc score. Score ≥2 (men) or ≥3 (women): anticoagulation recommended. Consider heparin bridge in ED if indicated.; time: ; drugs:
Source and review
- AHA/ACC/HRS AF Guidelines 2023; January et al., JACC 2019. Last reviewed: 2024-11-01