Atrial fibrillation
Drugs for rate control in AF
Beta-blockers
Metoprolol tartrate
Metoprolol XL succinate
Bisoprolol
Atenolol
Nebivolol
Carvedilol
Intravenous administration
2.5 - 5 mg bolus over 2 min; up to 15 mg maximal accumulative dose
Oral maintainance dose
25–100 mg twice daily
50–200 mg once daily
1.25–20 mg once daily
25–100 mg once daily
2.5–10 mg once daily
3.125–50 mg twice daily
Contraindications and cautions: Asthma, acute heart failure, history of severe bronchospasm.
Non-dihydropyridine calcium channel antagonists
Verapamil
Diltiazem
2.5–10 mg i.v. bolus over 5 min
0.25 mg/kg i.v. bolus over 5 min, then impairment. 5–15 mg/h
Intravenous administration
Oral maintainance dose
40 mg twice daily to 480 mg (extended release) once daily
60 mg three times daily to 360 mg (extended release) once daily
Contraindications and cautions: HFrEF, adjust doses in hepatic and renal impairment.
Digitalis glycosides
Digoxin
0.5 mg i.v. bolus (0.75–1.5 mg over 24 h in divided doses)
Intravenous administration
Oral maintainance dose
0.0625–0.25 mg once daily
Check renal function before starting digoxin and adapt dose in CKD patients.
Drugs for rhythm control in AF
Intravenous administration
Flecainide
1-2 mg/kg over 10 min
Oral maintainance dose
200-300 mg then 50−150 mg twice daily
success rate
50%–60% at 3 h and 75%–85% at 6–8 h (3–8 h)
Propafenone
1.5–2 mg/kg over 10 min
450–600 mg then 150-300 mg three times daily
success rate
45%–55% at 3 h, 69%–78% at 8 h (3–8 h)
Should not be used in patients with severe structural or coronary artery disease, Brugada syndrome, or severe renal failure (CrCl <35 mL/min/1.73 m2 )
Related topics: Antiarrhythmic drugs class I
Other
Amiodarone
Intravenous administration
300 mg i.v. Diluted in 250 mL 5% dextrose over 30–60 min, followed by 900–1200 mg i.v. over 24 h diluted in 500–1000 mL
(Concentrations more than 1000 mg/ 500 ml may cause phlebitis suggestion infusion via a central venous cannula )
Oral maintainance dose
200 mg once daily after loading
(Reduced dose in Thais)
Consider numerous drug interactions. Serious potential adverse effects (including pulmonary, ophthalmic, hepatic, and thyroid). May cause hypotension, bradycardia/ atrioventricular block, QT prolongation.
Electrical cardioversion (AF onset < 24 h, unstable)
-
Blood pressure monitoring and oximetry should be conducted regularly.
-
Intravenous atropine, isoproterenol, or temporary transcutaneous pacing must be readily accessible for post-cardioversion bradycardia.
-
Biphasic defibrillators are the standard choice due to their greater effectiveness compared to monophasic defibrillators.
-
Sedation can be achieved with intravenous midazolam, propofol, or etomidate.
-
Initiate unfraction heparin (UFH) for unscheduled emergency cardioversion.
-
Short-term OAC after cardioversion (4 weeks) for all patients. Long-term OAC, according to CHA2DS2-VA.
Improving the success rate of electrical cardioversion
-
Pre-treatment with vernakalant, flecainide, ibutilide, propafenone, or amiodarone enhances the success rate of electrical cardioversion and can help maintain long-term sinus rhythm by reducing early recurrent atrial fibrillation.
-
Active compression on the defibrillation pads is linked to lower defibrillation thresholds, reduced total energy delivery, fewer shocks needed for successful electrical cardioversion, and higher success rates.
-
Maximum fixed-energy shocks (200 J) have proven more effective than low-escalating energy for electrical cardioversion(120 --> 200 J).
-
There is no significant difference in the restoration of sinus rhythm when comparing anterior-posterior and anterolateral electrode placements.
References
1) Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D; ESC Scientific Document Group. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024 Sep 29;45(36):3314-3414. doi: 10.1093/eurheartj/ehae176. PMID: 39210723.
2) Milojevic, Kolia et al. “Esmolol Compared with Amiodarone in the Treatment of Recent-Onset Atrial Fibrillation (RAF): An Emergency Medicine External Validity Study.” The Journal of emergency medicine 56 3 (2019): 308-318 .