Atrial fibrillation with rapid ventricular response

Last updated: November 27, 2023

CME information and disclosurestoggle arrow icon

To see contributor disclosures related to this article, hover over this reference: [1]

Physicians may earn CME/MOC credit by searching for an answer to a clinical question on our platform, reading content in this article that addresses that question, and completing an evaluation in which they report the question and the impact of what has been learned on clinical practice.

AMBOSS designates this Internet point-of-care activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

For answers to questions about AMBOSS CME, including how to redeem CME/MOC credit, see "Tips and Links" at the bottom of this article.

Summarytoggle arrow icon

Atrial fibrillation with rapid ventricular response (Afib with RVR) is Afib with a ventricular rate > 100–110/minute. Afib with RVR can lead to impairment of cardiac output and hemodynamic instability due to shortened ventricular filling time and increased myocardial oxygen demand. Long-term Afib with RVR may lead to tachycardia-induced cardiomyopathy. Affected individuals typically present with palpitations, but may be asymptomatic or also have signs of hemodynamic instability. Diagnosis is based on ECG findings. The typical appearance of Afib with RVR is an irregularly irregular narrow-complex tachycardia (NCT) without discernable P waves. The presence of a wide-complex tachycardia (WCT) raises the likelihood of preexcited Afib, Afib with aberrant conduction, and other WCTs, e.g., ventricular tachycardia (VT). Acute management depends on clinical stability, symptom duration, and comorbid conditions. Treatment typically involves rate control or rhythm control followed by the identification and management of reversible Afib triggers. Although the ECG findings of atrial flutter with RVR differ (e.g., usually a regular rhythm with a rate dependent on the conduction ratio), its initial management and stabilization are the same as the treatment of Afib with RVR.

See “Atrial fibrillation” for a comprehensive diagnosis and long-term management of Afib and atrial flutter.

Clinical featurestoggle arrow icon

See also “Clinical features of atrial fibrillation” and “Clinical features” in “Atrial flutter.”

Conduct a careful clinical evaluation to determine whether the tachycardia is the primary cause of hemodynamic instability or a response to shock due to an underlying condition (e.g., sepsis, hypovolemia, massive PE), especially in patients with longstanding Afib. [4]

Managementtoggle arrow icon

The following focuses on acute management of Afib with RVR and atrial flutter with RVR. For long-term therapy, see “Management of atrial fibrillation” and “Treatment” in “Atrial flutter.”

Initial management [5][6]

Unstable Afib with RVR [5][6]

Emergency electrical cardioversion

Supportive management

Manage unstable Afib with immediate synchronized electrical cardioversion. Do not delay emergency electrical cardioversion for anticoagulation.

Stable Afib with RVR

Clinical decision-making resembles the approach to a new diagnosis of Afib without RVR. If the diagnosis is uncertain, follow the approach for undifferentiated stable, irregular narrow-complex tachycardia.

Disposition [4]

  • Patients presenting to the ED with RVR typically undergo a trial of rate control or rhythm control followed by a period of observation.
  • Hospital admission is required for symptomatic patients unresponsive to ED management.
  • Consider cardiology consult and ICU admission for patients with persistently unstable or refractory tachycardia.
  • Consider discharge with close outpatient cardiology follow-up in stable, asymptomatic patients if:
  • Follow local protocols and consider cardiology consultation prior to discharge. [11]

Diagnosticstoggle arrow icon

See “Afib diagnostics” for details.

Irregularly irregular NCT with a rate > 100–110/minute and no discernable P waves on ECG strongly suggests Afib with RVR.

Regular NCT with a rate of 150/minute with sawtooth P waves on ECG suggests rapid atrial flutter with 2:1 conduction. Treatment is the same as for rapid Afib.

Exercise caution if there is a WCT since the differential diagnoses include preexcited Afib, Afib with aberrant conduction, atrial flutter with aberrant conduction or preexcitation, ventricular tachycardia, and other SVT with aberrancy. These diagnoses require a specialized approach.

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

For stable patients, choose the optimal strategy based on the individual patient's risk profile in consultation with a specialist (see “Rhythm control vs. rate control” for details); for unstable Afib, emergency electrical cardioversion is the treatment of choice.

Administer rate control with IV medications and/or rhythm control for Afib with RVR in monitored acute care settings.

Rate control [5][9]

For long-term maintenance therapy, see “Rate control” in “Atrial fibrillation.”

Avoid rate control medications in the management of preexcited Afib as they are all AV nodal blockers that can precipitate Vfib due to uncontrolled ventricular conduction via the accessory pathway. [5][7]

Options [5][7]

IV agents are recommended in the acute setting; consider combination with oral medications. [5][12]

Avoid IV beta blockers and ndHP CCBs in patients with LV dysfunction and acute decompensated heart failure as these can compromise hemodynamic function. [5][7]

For rate control in pregnant individuals, beta blockers are preferred. CCBs and digoxin can be used in consultation with a specialist. Amiodarone can be harmful and should be avoided. [13][14]

Rhythm control (e.g., cardioversion) [5][6][9]

Can safely be used to convert Afib with RVR back to sinus rhythm in select patients for whom this is desirable.

Options [5]

Monitor for QTc prolongation and torsades de pointes in patients receiving dofetilide or ibutilide. [5]

Avoid flecainide and propafenone in patients with coronary artery disease and significant structural heart disease. [5]

Electrical cardioversion is preferred over pharmacological cardioversion for rhythm control in pregnant individuals. [13][14]

Comorbid conditionstoggle arrow icon

Consult cardiology early whenever complicating factors (e.g., ACS, chronic HF, preexcited Afib) are present or suspected alongside Afib with RVR.

Afib with acute coronary syndrome [5][6]

Afib with heart failure [5][20]

See also “Tachycardia-induced cardiomyopathy.”

Preexcited Afib (Afib with WPW)

WPW is the most common preexcitation pattern, however, other accessory pathways may also underlie this presentation.


Consider preexcited Afib in at-risk patients with irregularly irregular WCT.

Management of preexcited Afib [24]

See “Stable, wide-complex tachycardia” for details on differentiating preexcited Afib from other irregular WCTs.

Avoid AV nodal blockers and amiodarone in patients with preexcited Afib as these can trigger Vfib.

Hemodynamic instability is common in patients with preexcited Afib and other irregular WCTs (e.g., polymorphic Vtach). When in doubt, treat with electrical cardioversion!

Acute management checklisttoggle arrow icon

Referencestoggle arrow icon

  1. $Contributor Disclosures - Atrial fibrillation with rapid ventricular response. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  2. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia. Circulation. 2016; 133 (14): p.e506–e574.doi: 10.1161/cir.0000000000000311 . | Open in Read by QxMD
  3. Fischer A, Ousdigian KT, Johnson JW, Gillberg JM, Wilkoff BL. The impact of atrial fibrillation with rapid ventricular rates and device programming on shocks in 106,513 ICD and CRT-D patients. Heart Rhythm. 2012; 9 (1): p.24-31.doi: 10.1016/j.hrthm.2011.08.005 . | Open in Read by QxMD
  4. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  5. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Circulation. 2014; 130: p.e199-e267.doi: 10.1161/CIR.0000000000000041 . | Open in Read by QxMD
  6. Neumar RW, Otto CW, Link MS, et al. Part 8: Adult Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122 (18_suppl_3): p.S729-S767.doi: 10.1161/circulationaha.110.970988 . | Open in Read by QxMD
  7. Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020; 142 (16_suppl_2).doi: 10.1161/cir.0000000000000916 . | Open in Read by QxMD
  8. Means K, Gentry A, Nguyen T. Intravenous Continuous Infusion vs. Oral Immediate-release Diltiazem for Acute Heart Rate Control. Western Journal of Emergency Medicine. 2018; 19 (2): p.417-422.doi: 10.5811/westjem.2017.10.33832 . | Open in Read by QxMD
  9. Mehta LS, Warnes CA, Bradley E, et al. Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020; 141 (23).doi: 10.1161/cir.0000000000000772 . | Open in Read by QxMD
  10. Tamirisa KP, Elkayam U, Briller JE, et al. Arrhythmias in Pregnancy. JACC: Clinical Electrophysiology. 2022; 8 (1): p.120-135.doi: 10.1016/j.jacep.2021.10.004 . | Open in Read by QxMD
  11. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2019; 74 (1): p.104-132.doi: 10.1016/j.jacc.2019.01.011 . | Open in Read by QxMD
  12. Kirchhof P, Camm AJ, Goette A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020; 383 (14): p.1305-1316.doi: 10.1056/nejmoa2019422 . | Open in Read by QxMD
  13. Rillig A, Magnussen C, Ozga AK, et al. Early Rhythm Control Therapy in Patients With Atrial Fibrillation and Heart Failure. Circulation. 2021; 144 (11): p.845-858.doi: 10.1161/circulationaha.121.056323 . | Open in Read by QxMD
  14. Cordina J, Mead G. Pharmacological cardioversion for atrial fibrillation and flutter. Cochrane Database Syst Rev. 2005: p.CD003713.doi: 10.1002/14651858.CD003713.pub2 . | Open in Read by QxMD
  15. Stiell IG, Clement CM, Perry JJ, et al. Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM. 2010; 12 (03): p.181-191.doi: 10.1017/s1481803500012227 . | Open in Read by QxMD
  16. Stiell IG, Clement CM, Rowe BH, et al. Outcomes for Emergency Department Patients With Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals. Ann Emerg Med. 2017; 69 (5): p.562-571.e2.doi: 10.1016/j.annemergmed.2016.10.013 . | Open in Read by QxMD
  17. Link MS, Atkins DL, Passman RS, et al. Part 6: Electrical Therapies: Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing * 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122 (18_suppl_3): p.S706-S719.doi: 10.1161/circulationaha.110.970954 . | Open in Read by QxMD
  18. Atzema CL, Barrett TW. Managing atrial fibrillation.. Ann Emerg Med. 2015; 65 (5): p.532-9.doi: 10.1016/j.annemergmed.2014.12.010 . | Open in Read by QxMD
  19. Barrett TW, Self WH, Jenkins CA, et al. Predictors of Regional Variations in Hospitalizations Following Emergency Department Visits for Atrial Fibrillation. Am J Cardiol. 2013; 112 (9): p.1410-1416.doi: 10.1016/j.amjcard.2013.07.005 . | Open in Read by QxMD
  20. DiMarco JP. Atrial Fibrillation and Acute Decompensated Heart Failure. Circulation: Heart Failure. 2009; 2 (1): p.72-73.doi: 10.1161/circheartfailure.108.830349 . | Open in Read by QxMD
  21. Kelly JP, DeVore AD, Wu J, et al. Rhythm Control Versus Rate Control in Patients With Atrial Fibrillation and Heart Failure With Preserved Ejection Fraction: Insights From Get With The Guidelines—Heart Failure. J Am Heart Assoc. 2019; 8 (24).doi: 10.1161/jaha.118.011560 . | Open in Read by QxMD
  22. Hollenberg SM, Heitner S. Cardiology in Family Practice. Springer Science & Business Media ; 2011
  23. Atlee JL. Complications in Anesthesia. Elsevier Health Sciences ; 2007
  24. Elliott WJ, Varon J. Evaluation and treatment of hypertensive emergencies in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: August 16, 2016. Accessed: February 20, 2017.
  25. Panchal AR, Berg KM, Kudenchuk PJ, et al. 2018 American Heart Association Focused Update on Advanced Cardiovascular Life Support Use of Antiarrhythmic Drugs During and Immediately After Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2018; 138 (23).doi: 10.1161/cir.0000000000000613 . | Open in Read by QxMD

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer