Pharmacological Treatment for Atrial Fibrillation and Atrial Flutter.

Rapid Rate Control

	Loading Dose	Onset	Maintenance Dose	Adverse Reactions and Comment
Diltiazem. IV	20 mg over 2 min	2-7 min	IV, 5-15 mg/hr. Oral, 120-360 mg/d	Hypotension, bradycardia, heart failure.
Esmolol. IV	0.5 mg/kg over 1 min	5 min	0.05-0.2 mg/kg/min	Hypotension, bradycardia, asthma, when given during acute heart failure.
Metoprolol. IV	2.5-5.0 mg over 2-5 min, up to 15 mg	5 min	(IV-NI), Oral, 25-100 mg bid	Hypotension, bradycardia, asthma, when given during acute heart failure. Although Beta blocker is indicated in chronic heart failure).
Verapamil. IV	5-10 mg over 2 min	3-5 min	(IV-NI), Oral, 120-360 mg/d	Hypotension, bradycardia, heart failure.
Digoxin. IV	0.5 mg initially, then 0.25 mg q 2-4 hr, up to 1.0-1.5 mg	2 hr	IV or Oral, 0.125-0.375 mg/d	Slow onset, less effective with high cathecolamine, but safe in hypotensive patient. Bradycardia, GI upset, Yellow vision, arrhythmia.

NI = No information
Slower Rate Control and Chronic Rate Control.

	Loading Dose	Onset	Maintenance Dose	Adverse Reactions and Comment
Metoprolol. Oral		4-6 hr	25-100 mg bid	Hypotension, bradycardia, asthma,
Toprol XL. Oral			50-200 mg/d	Hypotension, bradycardia, asthma,
Diltiazem. Oral		2-4 hr	120-360 mg/d	Hypotension, bradycardia, heart failure. edema.
Verapamil. Oral		1-2 hr	120-360 mg/d	Hypotension, bradycardia, heart failure. edema.
Digoxin. Oral			0.125-0.375 mg/d	Bradycardia, GI upset, Yellow vision, arrhythmia. Insufficient rate controll during activity.
Amiodarone, Oral	400 mg bid for 2-3 wk	1-3 wk	200 mg/d (100-400)	Bradycardia, GI upset, photosensitivity, polyneuropathy. Pulmonary, thyroid and liver toxicity. Prolong QT, but rare Torsade
Sotalol, Oral			80-160 mg bid	Torsade, bradycardia, heart failure, asthma.
Dofetilide, Oral			125-500 mcg bid	Torsade. Require 3 days hospitalization

Pharmacological Cardioversion and Maintaining NSR

	Loading Dose	Success	Maintenance Dose	Adverse Reactions and Comment
Flecainide. Oral	300 mg		50-150 mg bid	Bradycardia, depress LV systolic function, hypotension, GI upset. Ventricular tachycardia (proarrhythmia) in patient with low LVEF.
Propafenone. Oral	300-600 mg	55-87%	150-300 mg tid	Possible same as above.
Amiodarone.	IV. 150 mg over 10 min, then 360 mg over next 6 hr. then 540 mg over next 18 hr. Oral. 400 mg bid for 2 wk.	45-85%	200 (100-400) mg/d.	Bradycardia, GI upset, photosensitivity, polyneuropathy. Pulmonary, thyroid and liver toxicity. Prolong QT, but rare Torsade
Sotalol, Oral	80-160 mg	52%	80-160 mg bid	Torsade, bradycardia, heart failure, asthma.
Procainamide	IV, 1000 mg over 30 min	58-65%	IV, 1-4 mg/min Oral, 500-1000 mg q 4-6 hr	Torsade, GI upset, positive antinuclear antibodies.
Dofetilide, Oral			125-500 mcg bid	Torsade. Require 3 days hospitalization.

Note that digitalis, beta blockers, and calcium channel blockers are not (or less) effective for cardioversion or maintaining NSR.