Emergency medicine updates: Atrial fibrillation with rapid ventricular response

Introduction: Atrial fibrillation (AF) may lead to stroke, heart failure, and death. When AF occurs in the context of a rapid ventricular rate/response (RVR), this can lead to complications, including hypoperfusion and cardiac ischemia. Emergency physicians play a key role in the diagnosis and management of this dysrhythmia. Objective: This paper evaluates key evidence-based updates concerning AF with RVR for the emergency clinician.Discussion: Differentiating primary and secondary AF with RVR and evaluating hemodynamic stability are vital components of ED assessment and management. Troponin can assist in determining the risk of adverse outcomes, but universal troponin testing is not required in patients at low risk of acute coronary syndrome or coronary artery disease -especially patients with recurrent episodes of paroxysmal AF that are similar to their prior events. Emergent cardioversion is indicated in hemodynamically unstable patients. Rate or rhythm control should be pursued in hemodynamically stable patients. Elective cardioversion is a safe option for select patients and may reduce AF symptoms and risk of AF recurrence. Rate control using beta blockers or calcium channel blockers should be pursued in those with AF with RVR who do not undergo cardioversion. Anticoagulation is an important component of management, and several tools (e.g., CHA2DS2-VASc) are available to assist with this decision. Direct oral anticoagulants are the first-line medication class for anticoagulation. Disposition can be challenging, and several risk assessment tools (e.g., RED-AF, AFFORD, and the AFTER (complex, modified, and pragmatic) scores) are available to assist with disposition decisions.Conclusion: An understanding of the recent updates in the literature concerning AF with RVR can assist emergency clinicians in the care of these patients.Published by Elsevier Inc.

Automated summary

This paper evaluates key evidence-based updates concerning atrial fibrillation (AF) with rapid ventricular rate/response (RVR) for emergency clinicians. Differentiating primary and secondary AF with RVR and evaluating hemodynamic stability are important in emergency department assessment and management. Cardioversion is indicated in unstable patients, while rate or rhythm control is recommended for stable patients. Anticoagulation is an essential part of management, and there are tools available to assist with this decision. Understanding recent literature updates on AF with RVR can aid emergency clinicians in providing care for these patients.