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*Hypotension
*Hypotension
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| [[Esmolol]]||*Bolus 0.5 mg/kg over one minute, followed by 50 µg/kg/min  *If, after 4min response is inadequate, re-bolus followed by infusion of 100 µg/kg/min  *If, after 4min response is still inadequate, try final bolus followed by infusion of 150 µg/kg/min  *If necessary, infusion can be increased to maximum of 200 µg/kg/min after another four minutes||*Use if unsure whether patient will tolerate a beta blocker since the duration of action is only 10 minutes||
| [[Esmolol]]||
*Bolus 0.5 mg/kg over one minute, followed by 50 µg/kg/min   
*If, after 4min response is inadequate, re-bolus followed by infusion of 100 µg/kg/min   
*If, after 4min response is still inadequate, try final bolus followed by infusion of 150 µg/kg/min   
*If necessary, infusion can be increased to maximum of 200 µg/kg/min after another four minutes
||
*Use if unsure whether patient will tolerate a beta blocker since the duration of action is only 10 minutes
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| Other||||||
| Other||||||
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| [[Digoxin]]||||||
| [[Digoxin]]||||||
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| ||*0.25 mg IV q2hr up to 1.5 mg, then 0.125-0.25 mg PO or IV QD  *Adjust dose in presence of renal failure, amiodarone, etc||*Consider as initial therapy for pts with LV dysfunction who:  **Do not achieve rate control targets on beta blockers alone  **Cannot tolerate addition of or increased doses of beta blocker due to decompensated CHF  **Would have digoxin added anyway to improve CHF symptoms independent of A-fib  *Consider as initial therapy in pts with severe hypotension  *Consider as 2nd agent in pts in whom IV BB or IV CCB has failed to control their rate  *May take up to 6-8 hours to work||
|  
||
*0.25 mg IV q2hr up to 1.5 mg, then 0.125-0.25 mg PO or IV QD   
*Adjust dose in presence of renal failure, amiodarone, etc
||
*Consider as initial therapy for pts with LV dysfunction who:   
**Do not achieve rate control targets on beta blockers alone   
**Cannot tolerate addition of or increased doses of beta blocker due to decompensated CHF   
**Would have digoxin added anyway to improve CHF symptoms independent of A-fib   
*Consider as initial therapy in pts with severe hypotension   
*Consider as 2nd agent in pts in whom IV BB or IV CCB has failed to control their rate   
*May take up to 6-8 hours to work
||
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| [[Amiodarone]]||*Load 3-7 mg/kg IV over 30 min; then 1200 mg over 24hr via continuous infusion or in divided oral dosesKhan IA et al. Amiodarone for pharmacological cardioversion of recent-onset atrial fibrillation. Int J Cardiol. 2003 Jun;89(2-3):239-48.||*Consider for patients with decompensated heart failure or those with accessory pathways  *2nd-line agent for chronic rate control when BBs and CCBs, alone, combined, or when used with digoxin, are ineffective||
| [[Amiodarone]]||
*Load 3-7 mg/kg IV over 30 min; then 1200 mg over 24hr via continuous infusion or in divided oral dosesKhan IA et al. Amiodarone for pharmacological cardioversion of recent-onset atrial fibrillation. <ref>Int J Cardiol. 2003 Jun;89(2-3):239-48.</ref>
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*Consider for patients with decompensated heart failure or those with accessory pathways   
*2nd-line agent for chronic rate control when BBs and CCBs, alone, combined, or when used with digoxin, are ineffective
||
|}
|}

Revision as of 16:45, 27 February 2015

Medication Dose Comments Contraindications
Calcium-Channel Blockers
Diltiazem
  • Bolus 0.25 mg/kg (average adult dose 20mg) over 2 min
  • If, after 15min 1st dose is tolerated but inadequate re-bolus 0.35 mg/kg
  • If patient responds start infusion at 5-15mg/hr or give PO dilt 30mg QID
  • Preferred in patients with chronic lung such as Asthma and COPD[1]
  • Decompensated heart failure
  • Preexcitation (especially in pediatrics)
  • Significant hypotension
Beta-Blockers
Metoprolol
  • Bolus 2.5-5mg IVP over 2min q5min up to 3 doses
  • If patient responds orally load with 25-50mg
  • Particularly useful when A-fib a/w exercise, after acute MI, or w/ thyrotoxicosis
  • Also long-term beta blocker improves patient survival whereas non-dihydropyridine calcium channel blockers may even worsen outcomes. Important to consider if a patient will most likely be started on a beta blocker upon discharge then strongly consider using the agent for acute conversion if they do not have any relative contraindications.[2]
  • COPD
  • Asthma
  • Decompensated heart failure
  • Hypotension
Esmolol
  • Bolus 0.5 mg/kg over one minute, followed by 50 µg/kg/min
  • If, after 4min response is inadequate, re-bolus followed by infusion of 100 µg/kg/min
  • If, after 4min response is still inadequate, try final bolus followed by infusion of 150 µg/kg/min
  • If necessary, infusion can be increased to maximum of 200 µg/kg/min after another four minutes
  • Use if unsure whether patient will tolerate a beta blocker since the duration of action is only 10 minutes
Other
Digoxin
  • 0.25 mg IV q2hr up to 1.5 mg, then 0.125-0.25 mg PO or IV QD
  • Adjust dose in presence of renal failure, amiodarone, etc
  • Consider as initial therapy for pts with LV dysfunction who:
    • Do not achieve rate control targets on beta blockers alone
    • Cannot tolerate addition of or increased doses of beta blocker due to decompensated CHF
    • Would have digoxin added anyway to improve CHF symptoms independent of A-fib
  • Consider as initial therapy in pts with severe hypotension
  • Consider as 2nd agent in pts in whom IV BB or IV CCB has failed to control their rate
  • May take up to 6-8 hours to work
Amiodarone
  • Load 3-7 mg/kg IV over 30 min; then 1200 mg over 24hr via continuous infusion or in divided oral dosesKhan IA et al. Amiodarone for pharmacological cardioversion of recent-onset atrial fibrillation. [3]
  • Consider for patients with decompensated heart failure or those with accessory pathways
  • 2nd-line agent for chronic rate control when BBs and CCBs, alone, combined, or when used with digoxin, are ineffective
  1. ↑ Short PM, Lipworth SI, Elder DH, Schembri S, Lipworth BJ. Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study. BMJ. 2011 May 10;342:d2549
  2. ↑ Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999 Jun 12;353(9169):2001-7Effect of verapamil on mortality and major events after acute myocardial infarction (the Danish Verapamil Infarction Trial II–DAVIT II). Am J Cardiol. 1990 Oct 1;66(10):779-85
  3. ↑ Int J Cardiol. 2003 Jun;89(2-3):239-48.
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