A-fib with RVR

Rapid rate-vs-rhythm and agent selection for acute atrial fibrillation with rapid ventricular response — with the contraindications a hospitalist needs flagged up front.

1 · Hemodynamic stability

2 · Clinical context (tap all that apply)

Always consider

Treat the trigger (PIRATES)

Pulmonary (PE, pneumonia, hypoxia) · Ischemia · Rheumatic/valve · Anemia/Autonomic · Thyroid · EtOH/Electrolytes (K, Mg) · Sepsis/Surgery/Sleep apnea. Secondary AF often won't rate-control until the driver is fixed.

Rate target

Lenient <110 bpm at rest if asymptomatic with preserved EF (RACE II). Strict <80 if symptomatic or LV dysfunction.

Anticoagulation

Score stroke risk (CHA₂DS₂-VASc). Start/plan anticoagulation per risk & bleeding; valvular/mechanical valve → warfarin.

Cardioversion timing

If AF >48 h or unknown: 3 wks therapeutic AC first or TEE to exclude thrombus, then 4 wks AC after. Unstable → cardiovert now, anticoagulate ASAP.

Dosing quick-reference

Metoprolol

(tartrate) IV 2.5–5 mg over 2 min, repeat q5min ×up to 3 (max 15 mg) → PO 25–100 mg q6–12h. Cardioselective.

Esmolol

500 mcg/kg IV bolus → 50–200 mcg/kg/min. Ultra-short, titratable — good if borderline BP / critically ill.

Diltiazem

0.25 mg/kg IV over 2 min (~15–20 mg); repeat 0.35 mg/kg (~20–25 mg) in 15 min PRN → infusion 5–15 mg/h; PO 120–360 mg/day.

Verapamil

2.5–5 mg IV over 2 min, may repeat. More negative inotropy than diltiazem.

Digoxin

Load 0.25–0.5 mg IV, then 0.25 mg q6h (max ~1.5 mg/24h); maint 0.125–0.25 mg/day (renal). Slow onset (hrs); weak if high catecholamines.

Amiodarone

150 mg IV over 10 min → 1 mg/min ×6h → 0.5 mg/min ×18h. Rate control + may chemically cardiovert (observe AC / 48-h rule).

Magnesium

2 g IV over 15–30 min (adjunct; especially if Mg low).

Cardioversion

Synchronized 120–200 J biphasic, with sedation (ACLS).

Procainamide

15–17 mg/kg IV over 30–60 min — for pre-excited (WPW) AF; or cardiovert.

Med Topo · Tools — an educational decision aid for the common case; not a substitute for ACLS protocols, cardiology input, or clinical judgment. Verify every dose and individualize to your patient, renal/hepatic function, and local protocol. · Back to Tools