From the Guidelines
For rapid atrial fibrillation management, the recommended initial drug doses include metoprolol 2.5 to 5 mg IV bolus over 2 min, diltiazem 0.25 mg/kg IV over 2 min, and esmolol 500 mcg/kg IV over 1 min, as these medications have been shown to effectively control heart rate and reduce symptoms in patients with AF 1.
Medication Options for Rate Control
The following medications are recommended for rate control in patients with AF:
- Metoprolol: 2.5 to 5 mg IV bolus over 2 min, repeated up to 3 doses, followed by 25 to 100 mg orally twice daily 1
- Diltiazem: 0.25 mg/kg IV over 2 min, with a second dose of 0.35 mg/kg if needed, then 5 to 15 mg/hour infusion or 120 to 360 mg daily oral dosing 1
- Esmolol: 500 mcg/kg IV bolus over 1 min, followed by 50 to 200 mcg/kg/min infusion 1
Considerations for Treatment Choice
Treatment choice depends on hemodynamic stability, duration of AF, and underlying cardiac conditions, with beta-blockers, diltiazem, verapamil, or digoxin recommended as first-choice drugs in patients with AF and LVEF >40% to control heart rate and reduce symptoms 1.
Additional Considerations
Anticoagulation should be considered for AF lasting longer than 48 hours to prevent thromboembolic complications, and the adequacy of heart rate control should be assessed during physical activity as well as at rest 1.
From the FDA Drug Label
For patients with PSVT and patients with PAF the recommended starting dose is 50 mg every 12 hours. Flecainide doses may be increased in increments of 50 mg bid every four days until efficacy is achieved For PAF patients, a substantial increase in efficacy without a substantial increase in discontinuations for adverse experiences may be achieved by increasing the flecainide dose from 50 mg to 100 mg bid. The maximum recommended dose for patients with paroxysmal supraventricular arrhythmias is 300 mg/day. The initial dose of diltiazem hydrochloride injection should be 0. 25 mg/kg actual body weight as a bolus administered over 2 minutes (20 mg is a reasonable dose for the average patient). The recommended initial infusion rate of diltiazem hydrochloride injection or diltiazem hydrochloride for injection is 10 mg/h.
The recommended drug doses for treating rapid atrial fibrillation (AF) are:
- Flecainide (PO): 50 mg every 12 hours, increased in increments of 50 mg bid every four days until efficacy is achieved, with a maximum recommended dose of 300 mg/day 2.
- Diltiazem (IV): 0.25 mg/kg actual body weight as a bolus administered over 2 minutes, followed by an infusion rate of 10 mg/h 3. Key points to consider:
- The dose of flecainide may be increased to 100 mg bid for PAF patients to achieve a substantial increase in efficacy.
- The infusion rate of diltiazem may be increased in 5 mg/h increments up to 15 mg/h as needed.
From the Research
Recommended Drug Doses for Treating Rapid Atrial Fibrillation (AF)
The following are some of the recommended drug doses for treating rapid atrial fibrillation (AF):
- Intravenous (i.v.) beta blockers and calcium channel blockers are equally effective in rapidly controlling the ventricular rate in acute AF in selected individuals 4
- The addition of digoxin to the regimen causes a favorable outcome, however, digoxin as a single agent is generally inefficacious in slowing the ventricular rate in acute AF 4
- In cases of ventricular preexcitation syndrome associated with rapid ventricular rate due to AF, the drug of choice is i.v. procainamide 4
- For patients with concomitant heart failure with a reduced ejection fraction (HFrEF), beta blockers (BB) such as metoprolol are preferred over non-dihydropyridine calcium channel blockers (CCB) such as diltiazem due to their potential negative inotropic effects 5
Rate Control Strategies
Rate control strategies for AF include:
- Beta blockers (BB) such as metoprolol 6, 5
- Non-dihydropyridine calcium channel blockers (CCB) such as diltiazem 6, 5
- Digoxin 6, 7
- Atrioventricular nodal ablation and pacing 6, 7
Treatment Approaches
Treatment approaches for AF include: