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Circulation. 2025;152(suppl 2):S538–S577. DOI: 10.1161/CIR.0000000000001376 October 21, 2025 S571

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ATRIAL FIBRILLATION AND FLUTTER WITH RAPID VENTRICULAR RESPONSE: PART 2 MEDICAL THERAPIES Recommendations for Medical Therapies for Atrial Fibrillation/Flutter COR LOE Recommendations

1 B-NR 1.  IV administration of a β-adrenergic blocker or nondihydropyridine calcium channel antagonist is recommended to slow the ventricular heart rate in the acute setting in adult patients with atrial fibrillation or atrial flutter with rapid ventricular response without preexcitation.

2a B-NR 2.  IV amiodarone can be useful for rate control in critically ill adult patients with atrial fibrillation with rapid ventricular response without preexcitation.

3: Harm C-LD 3.  In adult patients with preexcitation atrial fibrillation or atrial flutter, digoxin, nondihydropyridine calcium channel antagonists, β-adrenergic blockers, and IV amiodarone should not be administered because they may increase the ventricular response and result in VF.

3: Harm C-EO 4.  Nondihydropyridine calcium channel antagonists and IV β-adrenergic blockers should not be used in adult patients with left ventricular systolic dysfunction and decompensated heart failure because these may lead to further hemodynamic compromise.

Synopsis Control of rapid heart rates in the emergency setting are achievable using an intravenous nondihydropyridine calcium channel antagonist (eg, diltiazem, verapamil) or β-adrenergic blocker (eg, metoprolol, esmolol). Pharmacologic rhythm control (chemical cardioversion) employs intravenous drugs such as amiodarone, procainamide, or sotalol to convert AF/flutter to sinus rhythm and prevent its recurrence. Amiodarone is unique in that it can also be used for rate control in patients with heart failure in

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