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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e61

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

with placebo in 1 multicenter RCT.5 However, other agents may be safer and more effective in achieving acute rate control. Intravenous diltiazem was more effective than intravenous digoxin in 2 small RCTs.6,7 One trial performed at an emergency department at an academic center randomized 150 patients with AF without major comorbidities and a ventricular rate >120 bpm in a 1:1:1 ratio to intravenous diltiazem, digoxin, and amiodarone.6 The time to reduce the heart rate <90 bpm was significantly shorter in the diltiazem group compared with either digoxin or amiodarone, with fewer symptoms and shorter hospital lengths of stay. Another RCT of 30 patients randomized patients with AF and a rapid ventricular response to either intravenous diltiazem, digoxin, or a combination of both agents. Treatment with intravenous diltiazem significantly decreased heart rate within 5 minutes versus 3 hours with intravenous digoxin.7 Intravenous diltiazem reduced heart rate more rapidly than intravenous digoxin in a doubleblinded RCT in 40 patients with rapid AF after CABG, with similar control at 12 to 24 hours. In another RCT of 84 patients in rapid AF who presented to the emergency department, intravenous amiodarone resulted in faster control of the ventricular response compared with intravenous digoxin.8 Finally, 52 patients with rapid AF were randomized to receive either an intravenous combination of diltiazem and digoxin or intravenous diltiazem alone, with a more rapid and durable response to the combination.9

3 In addition to atrioventricular nodal blockers and

antiarrhythmics, intravenous magnesium has been investigated for rate controlling rapid AF. 10,11 The mechanism likely stems from blockade of slow inward calcium channels in the sinoatrial and atrioventricular node, thereby slowing the heart rate and prolonging atrioventricular conduction velocity, respectively.16 Its low adverse effect profile

Table 21.  Pharmacological Agents for Rate Control in Patients With AF Intravenous Administration Oral Maintenance Dose Elimination Half-Life Notes Beta blockers Metoprolol tartrate 2.5-5 mg bolus over 2 min; up to 3 doses 25-200 mg, twice daily 3-4 h Metoprolol succinate N/A 50-400 mg daily or twice daily in divided doses 3-7 h Atenolol N/A 25-100 mg daily 6-7 h Renally eliminated Bisoprolol N/A 2.5-10 mg daily 9-12 h Carvedilol N/A 3.125-25 mg, twice daily 7-10 h Esmolol 500 μg/kg bolus over 1 min; then 50-300 μg/kg/min N/A 9 min Nadolol N/A 10-240 mg daily 20-24 h Propranolol 1 mg over 1 min; repeat as needed every 2 min; up to 3 doses 10-40 mg, 3-4 times daily IV: 2.4 h Oral: 3-6 h ER: 8-20 h Nondihydropyridine calcium channel blockers Diltiazem 0.25 mg/kg (actual body weight) IV over 2 min May repeat 0.35 mg/kg over 2 min; then 5-15 mg/h continuous infusion 120-360 mg daily (ER) IV: 3-5 h Oral immediate release: 3-4.5 h ER: 4-9.5 h Avoid in HFrEF Verapamil 5-10 mg over ≥2 min (may repeat twice); then 5 mg/h continuous infusion (max 20 mg/h) 180-480 mg daily (ER) IV: 6-8 h Oral: 2-7 h ER: 12-17 h Avoid in HFrEF Digitalis glycoside Digoxin 0.25-0.5 mg over several min; repeat doses of 0.25 mg every 6 h (maximum 1.5 mg/24 h) 0.0625-0.25 mg daily 1-2 d Renally eliminated Increased mortality at plasma concentrations exceeding 1.2 ng/mL Other Amiodarone 150-300 mg IV over 1 h, then 10-50 mg/h over 24 h 100-200 mg daily (generally IV form used for rate control) IV: 9-36 d Oral: 26-107 d Loading dose 6-10 g administered over 2-4 wk; can combine IV and oral dosing to complete

AF indicates atrial fibrillation; ER, extended release; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; and N/A, not applicable.

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