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Atrial Fibrillation with RVR
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Atrial Fibrillation with Rapid Ventricular Response (RVR)
By: Amanda Nguyen
Case Study
A 68-year-old, male, comes into the emergency department with complaints of chest pain, shortness of breath, and fatigue. He explains, “Doc, I feel like my heart is beating out of my chest!”. He states that he has had these symptoms for the past few months, but has worsened since he took on a stressful job a few weeks ago, which has caused him to increase his alcohol intake to decompress when he gets home everyday from work. He shows no signs of altered mental status, and is A&O x 3. Patient’s vitals are as follows: 160 bpm, 128/82 mmHg, 22 breaths per minute, and 97.5 F. The ED physician orders an EKG in the meantime.
EKG Findings
EKG Findings
- No p-waves before the QRS - no coordinated atrial contractions
- Heart rate is irregular (ventricles receiving irregular impulses)
What are we suspecting?
What are we suspecting?
Atrial Fibrillation with Rapid Ventricular Response (RVR)
- Faulty electrical signals/impulses of the atria that causes the atria to fibrillate/quiver rapidly and heart rate is irregular (atrial fibrillation)
- Which then can also affect the ventricles and cause it to beat chaotically as well (rapid ventricular response)
- if heart beats too fast, it is unable to fill with blood and causes decreased efficiency of the circulatory system as a whole
- also known as a tachyarrhythmia
Risks
Risks
- Uncontrolled HTN
- Elevated BMI
- Past history of heart attack or congestive heart failure
- Family history of atrial fibrillation
- Advanced age (increases after 60 years of age)
- Other chronic health conditions (sleep apnea, diabetes, lung disease, hyperthyroidism, alcohol abuse)
Triggers
Triggers
- Sleep deprivation
- Increased alcohol consumption
- Illness
- Increased stress
- Hormonal changes
- Strenuous exercise
- Caffeine
Symptoms
Symptoms
- Palpitations
- Fatigue
- Chest pain
- Weakness
- Reduced ability to exercise
- Dizziness
- Lightheadedness
- Confusion
- Shortness of breath
- Passing out/syncope
Diagnosis
Diagnosis
- EKG
- Holter monitor (24 hours)
- Event recorder (holter monitor that can be worn up to 1 month)
- Chest X-ray
- Stress test
- ECHO
- CMP, CBC, TSH, serial cardiac enzymes (troponin, CK, CK-MB)
Stable or Unstable?
Stable or Unstable?
- Our patient is currently stable
- Unstable:
- HR >120 with signs of instability such as:
- SBP < 90 with altered mental status, lightheadedness, chest pain, or shortness of breath
- Signs of acute cardiac ischemia (chest pain, EKG changes, troponin elevation)
- Signs of acute heart failure (acute respiratory distress, pulmonary edema)
Complications
Now imagine...
As the patient is awaiting his EKG, the nurse looks over and sees that the patient doesn't look that great. She sees the right side of his face begin to droop. She asks him to lift up both his arms, and he can only lift up his left arm. She says, "Sir, are you okay?" and he only replies with slurred speech.
What happened?
Stroke
Complications
Complications
- Heart failure
- Stroke
- Heart attack / myocardial infarction
- Low blood flow -> end organ damage
Treatments
Treatment
Medical Management
- Anti-arrhythmic / Rhythm control
- Flecainide, propafenone, dofetilide, amiodarone, sotalol
- Beta-blockers or Calcium Channel Blockers (rate control)
- Beta blockers: Propanolol, esmolol, metoprolol
- Calcium channel blockers: Diltiazem, verapamil
- Digoxin
- Anticoagulants
- IV heparin, warfarin, dabigatran, rivaroxaban, apixaban, edoxaban
Dosages
Dosages
Medical Procedures
Medical Procedures
Cardioversion
Cardioversion
- must be done in patients that are UNSTABLE
- two forms:
- patient is sedated with a dose of etomidate (0.1 mg/kg) and delivered a brief electrical shock via defibrillator pads/electrodes at 120-200J to momentarily stop the heart and shock it to reset into normal rhythm
- patient is given high doses of anti-arrhythmics with constant heart monitoring to regulate heart's rhythm
Surgical Treatment
Surgical Treatment
- when medical management and cardioversion fail
- Catheter ablation
- freezing/cryoablation or heating/radiofrequency areas of the heart that are misfiring to kill the tissue and restore normal rhythm
- Atrioventricular node ablation
- radiofrequency destroys small areas of tissues that connect the atrias to ventricles
- must implant pacemaker after
- Surgical maze procedure
- open heart surgery to create scar tissue in certain areas of the heart to stop electrical impulses from misfiring
Citations
Citations
- Moskowitz A, Chen KP, Cooper AZ, Chahin A, Ghassemi MM, Celi LA. Management of Atrial Fibrillation with Rapid Ventricular Response in the Intensive Care Unit: A Secondary Analysis of Electronic Health Record Data. Shock. 2017 Oct;48(4):436-440. doi: 10.1097/SHK.0000000000000869. PMID: 28328711; PMCID: PMC5603354.
- J. Fletcher. “What is A-fib with RVR?”. Medical News Today. 2017. https://www.medicalnewstoday.com/articles/316488
- Pulse Cardiology Team. “What is Afib with RVR, Symptoms, and Treatment”. Pulse Cardiology. 2020. https://www.pulse-cardiology.com/afib-with-rvr-symptoms-and-treatment/
- J. Marcin, MD, and M.E. Ellis. “What are the Dangers of Afib with RVR?”. Healthline. 2018. https://www.healthline.com/health/atrial-fibrillation/rvr
- M. Ahmed, MD. “Afib with RVR - When the Heart Races out of Control”. Myheart.net: Take Control of Your Health. 2014. https://myheart.net/articles/afib-with-rvr-when-the-heart-races-out-of-control/
- S. Watson. “Afib with Rapid Ventricular Response (RVR)”. WebMD. 2022. https://www.webmd.com/heart-disease/atrial-fibrillation/afib-rapid-response
- P.F. Morales, MD. “Afib with RVR: The Essential Guide on Symptoms and Treatment. AFib Essentials”. Dr. AFib. 2021. https://drafib.com/blog/afib-with-rvr
- J.P. Cunha. “Is AFib with RVR Life-Threatening?”. EMedicineHealth. 2022. https://www.emedicinehealth.com/is_afib_with_rvr_life-threatening/article_em.htm
- R. Kamboj MD, and A.S. Elaghandala MD. “Step by step approach to Afib with RVR”. NYPQ Emergency Medicine. 2020. https://www.kwaktalk.org/ramer/rvr
- “Atrial Fibrillation”. Learn and Master ACLS. https://acls-algorithms.com/rhythms/atrial-fibrillation/comment-page-4/
- J. M. Rhode, S. E. Hartley, S. Hanigan, et. al. “Management of Acute Atrial Fibrillation and Atrial Flutter in Non-Pregnant Hospitalized Adults”. Michigan Medicine: University of Michigan. 2017. https://www.med.umich.edu/1info/FHP/practiceguides/Afib/afibfinal.pdf
THE END
Questions?