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October 21, 2025 Circulation. 2025;152(suppl 2):S538–S577. DOI: 10.1161/CIR.0000000000001376 S572

Wigginton et al Advanced Life Support: 2025 AHA Guidelines for CPR and ECC

whom calcium channel or β-adrenergic blockers may not be tolerated. These recommendations are supported by the “2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation” and a 2025 evidence update.1

Recommendation-Specific Supportive Text

1 Clinical trial evidence shows that nondihydropyri-

dine calcium channel antagonists (eg, diltiazem, verapamil) and β-adrenergic blockers (eg, metoprolol, esmolol, propranolol), are effective for rate control in patients with atrial fibrillation/flutter.2–9 Systematic reviews show that IV diltiazem improves heart rate control in atrial fibrillation/flutter without preexcitation with rapid ventricular response when compared to IV metoprolol.10–18 However, most of the included studies were limited by small sample size, retrospective data, and many did not report relevant clinical outcomes and comorbidities. Randomized clinical trials examining verapamil are lacking, thus, diltiazem is generally preferred. 2.	 Amiodarone is effective for rate control in patients

with atrial fibrillation/flutter without preexcitation in patients with contraindications for nondihydropyridine calcium channel antagonists or β-adrenergic blockers.2–9 Digoxin is less commonly used in the acute setting because of the slow onset of effect.19–21 In an observational study, the optimal amiodarone dosing for heart rate control (<115– 80/min) was examined in 80 critically ill patients, most with cardiogenic shock or sepsis.22 The dose needed to achieve heart rate control was nearly twice as high in patients with persistent versus paroxysmal atrial arrhythmias, but patients who were taking amiodarone prior to intensive care unit admission required lower doses. 3.	 Based on limited case reports and small case

series, there is concern that patients with concomitant preexcitation and atrial fibrillation or atrial flutter may develop VF in response to accelerated ventricular response after the administration of AV nodal blocking agents such as digoxin, nondihydropyridine calcium channel antagonists, β-adrenergic blockers, or IV amiodarone.23–26 In this setting, cardioversion is recommended as the most appropriate management. 4.	 Because of their negative inotropic effect, non-

dihydropyridine calcium channel antagonists (eg, diltiazem, verapamil) may further decompensate patients with left ventricular systolic dysfunction and symptomatic heart failure.7 Patients with heart failure with preserved ejection fraction may tolerate better nondihydropyridine calcium channel antagonists. While β-blockers can be safe in patients with cardiomyopathy, they can be harmful in patients who are decompensated.20,21,27 Limited evidence suggests that intravenous diltiazem may cause increased risk of decompensation compared to intravenous β-adrenergic blockers, but more data are needed to support preferential use.28 Multiple studies have demonstrated β-adrenergic blockers are safe for use in patients with chronic obstructive pulmonary disease.29 Refer to Table 2.

REFERENCES 1.	 Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM,

Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, et al; Peer Review Committee Members. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee

Table 2.  IV Medications Commonly Used for Acute Rate Control in Atrial Fibrillation and Atrial Flutter Medication Bolus dose Infusion rate Notes Nondihydropyridine calcium channel blockers Diltiazem 0.25 mg/kg IV bolus over 2 min 5–10 mg/h Avoid in hypotension, heart failure, cardiomyopathy, and acute coronary syndromes Verapamil 0.075–0.15 mg/kg IV bolus over 2 min; may give an additional dose after 30 min if no response 0.005 mg/kg per min Avoid in hypotension, heart failure, cardiomyopathy, and acute coronary syndromes β-Adrenergic blockers Metoprolol 2.5–5 mg over 2 min, up to 3 doses Avoid in decompensated heart failure Esmolol 500 mcg/kg IV over 1 min 50–300 mcg/kg per min Short duration of action; avoid in decompensated heart failure Propranolol 1 mg IV over 1 min, up to 3 doses Avoid in decompensated heart failure Other medications Amiodarone 300 mg IV over 1 h 10–50 mg/h over 24 h Multiple dosing schemes exist for amiodarone Digoxin 0.25 mg IV, repeated to maximum dose 1.5 mg over 24 h Typically used as adjunctive therapy with another option from above; caution in patients with renal impairment

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