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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e83 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation incidence increases substantially in patients with depressed LVEF.22 Most reported cases of ibutilide-associated nonsustained VT and torsades de pointes have occurred within 30 minutes after the last dose; torsades de pointes has rarely been reported as late as 2.5 hours after an ibutilide infusion.22 QTc intervals generally return to baseline within 2 to 3 hours after a dose. The risk of drug-induced torsades de pointes is higher in patients with hypokalemia and/or hypomagnesemia. Hypokalemia has been reported to be present in 17% to 70% of patients who have developed druginduced torsades de pointes.24–27 Similarly, hypomagnesemia has been reported to be a contributing factor to numerous published cases of drug-induced torsades de pointes.27–29 Therefore, maintenance of serum potassium and magnesium concentrations within the normal range is important before administration of ibutilide, and magnesium supplementation may mitigate the risk of torsades de pointes. Procainamide Intravenous procainamide is associated with hypotension in 5% to 12% of patients when used for management of AF,30,31 and BP monitoring is recommended. Intravenous procainamide is also associated with widening of the QRS complex and prolongation of the QT interval and may provoke proarrhythmia in the form of monomorphic VT32 and torsades de pointes.33 Sotalol Sotalol is a potent inhibitor of IKr, augments INa-L, and is associated with torsades de pointes, with an incidence ranging from 0.4% to 2.3%.34,35 Patients undergoing initiation or dose escalation of sotalol are often admitted for at least 3 days to a health care facility that can provide calculations of CrCl, continuous electrocardiographic monitoring, and cardiac resuscitation. A new intravenous form of sotalol was recently FDA approved, which may obviate the need for 3-day admission. After discharge on a stable dose of these drugs, a 12-lead ECG, and levels of serum magnesium, potassium, and creatinine are recommended every 3 to 6 months for assessment of QTc interval duration, electrolyte balance, and renal function, and more frequently for patients concomitantly taking other QT interval-prolonging drugs or with changing kidney function, to minimize the risk of drug-associated torsades de pointes. 8.3.4. Upstream Therapy Pharmacological treatments targeting upstream pathways have included glucocorticoids, ACE inhibitors, Table 25. Recommended Monitoring for Patients Taking Other Antiarrhythmic Drugs Drug Baseline Testing Follow-Up Testing Additional Follow-Up Testing Dofetilide 12-lead ECG* Continuous electrocardiographic monitoring during 3-d hospitalization for dofetilide initiation Serum potassium and magnesium concentration Serum creatinine for estimation of CrCl In 3-6 mo: 12-lead ECG* Serum potassium and magnesium concentration Serum creatinine for estimation of CrCl Every 3-6 mo (more frequently for patients concomitantly taking other QT interval-prolonging drugs or with changing kidney function: 12-lead ECG* Serum potassium and magnesium concentration Serum creatinine for estimation of CrCl Dronedarone 12-lead ECG* AST† ALT† Within first 6 mo: AST† ALT† – Ibutilide 12-lead ECG* Determination of serum potassium and magnesium concentrations and correction of hypokalemia and/or hypomagnesemia is recommended before initiation of the infusion Continuous electrocardiographic monitoring for assessment of QTc interval duration is recommended for at least 4 h after infusion or until the QTc has returned to baseline to minimize the risk of ibutilide-associated TdP – Procainamide 12-lead ECG* BP Electrocardiographic monitoring for assessment of rhythm, QRS width and QTc interval is recommended during the infusion to minimize the risk of procainamide-associated ventricular proarrhythmia, including TdP BP monitoring is recommended during the infusion to detect clinically relevant hypotension – Sotalol 12-lead ECG* Continuous electrocardiographic monitoring during 3-d hospitalization for sotalol initiation Serum potassium and magnesium concentration Serum creatinine for estimation of CrCl In 3-6 mo: 12-lead ECG* Serum potassium and magnesium concentration Serum creatinine for estimation of CrCl Every 3-6 mo (more frequently for patients concomitantly taking other QT interval-prolonging drugs or with changing kidney function: 12-lead ECG* Serum potassium and magnesium concentration Serum creatinine for estimation of CrCl *Assess rhythm and calculate QTc. †To facilitate early detection of potential dronedarone-associated hepatotoxicity. ALT indicates alanine transaminase; AST, aspartame transaminase; BP, blood pressure; ECG, electrocardiogram; CrCl, creatinine clearance; and TdP, torsades de pointes. Downloaded from http://ahajournals.org by on October 7, 2026