Management of rapid ventricular rate in acute atrial fibrillation

Atrial fibrillation (AF) with rapid ventricular response is a common tachyarrhythmia requiring hospitalization. The increased morbidity and mortality due to the hemodynamic consequences of acute AF is well recognized. Management strategies may be formed based on the evaluation of the entire clinical context including cardiovascular status and the associated noncardiac clinical disorders. Intravenous (i.v.) beta blockers and calcium channel blockers are equally effective in rapidly controlling the ventricular rate in acute AF in selected individuals. The addition of digoxin to the regimen causes a favorable outcome. However, digoxin as a single agent is generally inefficacious in slowing the ventricular rate in acute AF. These standard pharmacotherapies however, are contraindicated in ventricular preexcitation syndrome associated with rapid ventricular rate due to AF. In this situation the drug of choice is i.v. procainamide. When clinical condition is unstable or hemodynamically compromised, cardioversion is the treatment of choice in all cases of AF with rapid ventricular rate. Radiofrequency ablation of the AV node or anomalous tract may be considered in refractory or high risk subjects as a last resort.