What are the AHA/ACC/HRS guidelines for control of ventricular rate in patients with holiday heart syndrome (HHS)?

Updated: May 30, 2018
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jose M Dizon, MD  more...
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The 2014 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) guidelines include the following recommendations for control of ventricular rate in patients with atrial fibrillation (AF) [30] :

  • Beta-blockers or non-dihydropyridine calcium channel blockers are first-line agents for paroxysmal, persistent or permanent AF.

  • Intravenous (IV) beta-blockers or non-dihydropyridine calcium channel blockers may be used to slow ventricular heart rate in an acute setting in patients without preexcitation; in hemodynamically unstable patients, electrical cardioversion is indicated.

  • Consider IV amiodarone for rate control in critically ill patients without preexcitation if the condition limits the use of beta-blockers or calcium channel blockers.

  • In patients with AF symptoms during activity, assess heart rate control during exertion, adjusting drug treatment as needed.

  • Heart rate control (defined as <80 bpm at rest) may be considered for less symptomatic patients with AF; a more lenient rate-control strategy (<110 bpm at rest) is reasonable when patients remain asymptomatic and left ventricular (LV) systolic function is preserved.

  • In patients with inadequate ventricular rate control despite drug therapy, atrioventricular (AV) nodal ablation and pacemaker implantation may be considered.

  • AV nodal ablation should not be performed without prior attempts to achieve rate control with medications.

  • Non-dihydropyridine calcium channel blockers are contraindicated in decompensated heart failure.

  • With preexcitation syndrome and AF, non-dihydropyridine calcium channel blockers, digoxin, and IV amiodarone are contraindicated.

  • Dronedarone should not be used in patients with permanent AF or class III or IV heart failure.

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