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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e74

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

cardioversion,4–8 although intravenous amiodarone requires a longer time for AF conversion than ibutilide. Evidence from randomized studies support the efficacy of flecainide9–11 and propafenone10–14 for pharmacological cardioversion, and these drugs are reasonable for administration via the PITP approach for AF occurring outside of the hospital.16–18 Intravenous procainamide is more effective than placebo for pharmacological conversion of AF19 but is less effective than ibutilide.22,23 Dofetilide,24,25 oral amiodarone,26–28 and oral sotalol27,28 have been shown to be effective for conversion of AF to sinus rhythm but require several days for efficacy and therefore are not practical choices for acute pharmacological cardioversion. Data do not support intravenous sotalol for pharmacological cardioversion of AF.29,30

Recommendation-Specific Supportive Text 1.	 No studies compare the efficacy of electrical car-

dioversion with that of pharmacological cardioversion in patients with AF who are hemodynamically unstable. However, in a retrospective, propensity score-matched analysis of 374 hemodynamically

Table 22.  Drugs for Pharmacological Conversion of AF to Sinus Rhythm

Drug Route of Administration Loading Dose Maintenance Dose Approximate Time to Conversion to Sinus Rhythm Primary Route(s) of Elimination Elimination Half-Life Major Adverse Effects Amiodarone IV 5-7 mg/kg or 300 mg* 1200-3000 mg via continuous infusion over 24 h 8-12 h Liver metabolism Biliary excretion 9-36 d Bradycardia Hypotension QT prolongation Phlebitis TdP Flecainide Oral† 200 mg if <70 kg, 300 mg if >70 kg, single dose N/A 3-8 h Liver (70%) Kidney (30%)‡ 12-27 h Atrial flutter AV block Dizziness Dyspnea Exacerbation of HFrEF Headache Nausea QT prolongation VT Visual disturbances Ibutilide IV ≥60 kg: 1 mg over 10 min <60 kg: 0.01 mg/ kg over 10 min If arrhythmia does not terminate within 10 min after the end of the first infusion, may administer a second dose, equal to the first dose. N/A 30-90 min Liver 2-12 h Nonsustained VT QT prolongation TdP Procainamide IV 1 g over 30 min 2 mg/min continuous infusion over 1 h 30-60 min Liver (16-33%) Kidney (50-65%)‡ 3-4 h (parent) 7 h (NAPA) Agranulocytosis AV block Exacerbation of HFrEF Hypotension Neutropenia QT prolongation Rash Thrombocytopenia TdP Propafenone Oral 450 mg if <70 kg, 600 mg if >70 kg, single dose N/A 3-8 h Liver 9 h Atrial flutter AV block Dizziness Dyspnea Exacerbation of HFrEF Nausea Taste disturbances VT Visual disturbances *Some studies have administered intravenous amiodarone for 24 h followed by oral administration. †Flecainide is available in an intravenous dosage form in Europe. ‡Percentage of a dose excreted unchanged in urine. AV indicates atrioventricular; AF, atrial fibrillation; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; N/A, not applicable; NAPA, N-acetylprocainamide; TdP, torsades de pointes; and VT, ventricular tachycardia.

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