- If LVEF<40% or any sign of CHF, smallest dose of beta-blocker is recommended to achieve rate control.
- Amiodarone is an option to patient with haemodynamic instability or severely reduced LVEF.
- If LVEF>40%, beta-blocker or diltiazem or verapamil are recommended because of its rapid onset of action and effectiveness at high sympathetic tone compared to digoxin.
- In both condition, digoxin may be added to achieve initial resting heart rate target which is <110bpm.
Therapy
|
Acute Intravenous rate control
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Long-term oral rate control
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Comments
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Beta-Blocker
|
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Bisoprolol
|
Not available
|
1.25–20 mg once daily or split.
|
Bronchospasm is rare – in cases of asthma, recommend beta-1 selective agents (avoid carvedilol).
Contra-indicated in acute cardiac failure and a history of severe bronchospasm.
|
Carvedilol
|
Not available
|
3.125–50 mg BD.
|
|
Metoprolol
|
2.5–10 mg intravenous bolus
(repeated as required)
|
100–200 mg total daily dose
(according to preparation)
|
|
Nebivolol
|
Not available
|
2.5–10 mg once daily or split.
|
|
Esmolol
|
0.5 mg/kg intravenous bolus over
1 min; then 0.05–0.25 mg/kg/min.
|
||
Calcium Channel Blockers
|
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Diltiazem
|
15–25 mg intravenous bolus
(repeated as required)
|
60mg TDS up to 360mg total daily dose
(120-360mg OD modified release)
|
Use with caution in combination with beta-blockers. Reduce dose with hepatic impairment and start with smaller dose in renal impairment. Contra-indicated in LV failure with pulmonary congestion or LVEF <40%.
|
Verapamil
|
2.5–10 mg intravenous bolus
(repeated as required)
|
40-120mg TDS
(120-480mg OD modified release)
|
|
Cardiac glycosides
|
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Digoxin
|
0.5 mg intravenous bolus
(0.75–1.5 mg over 24 hours in
divided doses)
|
0.0625–0.25 mg daily dose
|
High plasma levels associated with increased risk of death. Check renal function before starting and adapt dose in patients with CKD. Contra-indicated in patients with accessory pathways, ventricular tachycardia and hypertrophic cardiomyopathy with outflow tract obstruction.
|
Digitoxin
|
0.4–0.6 mg intravenous bolus.
|
0.05–0.3 mg daily dose.
|
|
Specific Indications
|
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Amiodarone
|
300mg intravenously diluted in 250mL 5% dextrose over 30-60 minutes via central venous cannula.
*If ongoing requirement, 900mg diluted in 500-1000mL for over 24 hours.
|
200mg daily
|
Suggested as adjunctive therapy in patients where heart rate control cannot be achieved using combination therapy.
|
References:
- 2016 ESC Guidelines for the management of atrial fibrillation
- https://www.nice.org.uk/guidance/cg180/resources/atrial-fibrillation-management-pdf-35109805981381
- Pharmacologic Management of Newly Detected Atrial Fibrillation by AAFP, 2017
- Lexicomp
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