1) Afib RVR is often triggered by the same etiologies as sinus tachycardia. Before treating the arrhythmia, treat the most likely etiology.
2) In a person with normal cardiac function and structure, afib RVR is not the cause of the patients shock. Patients that are particularly sensitive to afib RVR include those with cardiomyopathies, recent MIs, severe diastolic dysfunction, HOCM, WPW, severe valvular disease, and severe coronary artery disease. In these populations, afib RVR often manifest as hypotension, pulmonary congestion, and possibly ischemia.
3) Procainamide should be the first line treatment in stable WPW with afib. AV nodal blocking agents should be avoided.
4) Review of recent literature suggest:
- Diltiazem is more effective at controlling rate within 30 minutes when compared to metoprolol (Fromm 2015).
- Beta blockers may have a mortality benefit when used in afib RVR & sepsis (Walkey 2016).
- Use of a rate of rhythm controlling agent in ED patients presenting with an acute underlying illness results in an increase in adverse events compared to patients who did not receive rate or rhythm controlling agents (Scheuremeyer 2015).
5) Physicians should make an effort to optimize care and improve blood pressures before choosing a rate/rhythm controlling agent. Physicians should consider the patient's clinical status and comorbidities when selecting a treatment option.