From the Guidelines
Intravenous flecainide or propafenone is the recommended medication for pharmacological cardioversion of recent-onset atrial fibrillation (AFib), excluding patients with severe left ventricular hypertrophy, heart failure with reduced ejection fraction (HFrEF), or coronary artery disease. When considering pharmacological cardioversion, the choice of medication depends on the patient's underlying cardiac condition and comorbidities.
- For patients with recent-onset AFib, intravenous flecainide or propafenone is recommended, as stated in the 2024 ESC guidelines for the management of atrial fibrillation 1.
- However, for patients with severe left ventricular hypertrophy, HFrEF, or coronary artery disease, intravenous amiodarone is recommended, accepting a potential delay in cardioversion 1.
- Additionally, intravenous vernakalant is an option for pharmacological cardioversion of recent-onset AFib, excluding patients with recent acute coronary syndrome (ACS), HFrEF, or severe aortic stenosis 1.
- It is essential to consider the potential risks and contraindications for each medication, such as proarrhythmia, bradycardia, and QT prolongation, particularly in patients with sinus node dysfunction, atrioventricular conduction disturbances, or prolonged QTc (>500 ms) 1.
- Prior to cardioversion, anticoagulation is crucial for patients with AFib lasting more than 48 hours or with unknown duration, and should be continued for at least 4 weeks after successful cardioversion.
- The medication dosing and administration should be carefully monitored, and the patient's cardiac function and comorbidities should guide the choice of medication.
From the FDA Drug Label
The pharmacokinetics of ibutilide fumarate injection in patients with atrial flutter or atrial fibrillation are similar regardless of the type of arrhythmia, patient age, sex, or the concomitant use of digoxin, calcium channel blockers, or beta-blockers. Clinical Studies Treatment with intravenous ibutilide fumarate for acute termination of recent onset atrial flutter/fibrillation was evaluated in 466 patients participating in two randomized, double-blind, placebo-controlled clinical trials Among patients with atrial flutter, 53% receiving 1 mg ibutilide fumarate and 70% receiving 2 mg ibutilide fumarate converted, compared to 18% of those receiving sotalol In patients with atrial fibrillation, 22% receiving 1 mg ibutilide fumarate and 43% receiving 2 mg ibutilide fumarate converted compared to 10% of patients receiving sotalol.
Ibutilide (IV) is used for cardioversion in atrial fibrillation (AFib) 2.
- The medication is administered intravenously.
- It is effective in converting atrial fibrillation to normal sinus rhythm, with conversion rates of 22% and 43% for 1 mg and 2 mg doses, respectively.
- The response to ibutilide is dose-related and more effective in patients with atrial flutter than fibrillation.
From the Research
Medications Used for Cardioversion in Atrial Fibrillation (AFib)
The following medications are used for cardioversion in AFib:
- Amiodarone 3, 4, 5
- Dofetilide 3, 4
- Ibutilide 3, 4, 5
- Propafenone 3, 6, 4, 7, 5
- Flecainide 3, 6, 4, 7
- Quinidine 3, 7
- Sotalol 6, 7, 5
- Vernakalant 4
- Azimilide 3
- Dronedarone 3
- Nibentan 3
- Ethacizine 3
- Disopyramide 3
- Procainamide 3
- Antazoline 4
Administration and Efficacy
These medications can be administered orally or intravenously, depending on the specific drug and the patient's condition. The efficacy of these medications varies, with some studies showing higher success rates for certain drugs, such as flecainide and propafenone 7. The choice of medication and administration route depends on various factors, including the patient's medical history, the duration of AFib, and the presence of underlying heart disease.
Safety and Adverse Effects
The safety and adverse effect profiles of these medications also vary. Some drugs, such as ibutilide, can cause QT prolongation and increase the risk of ventricular tachycardias 5. Others, such as amiodarone, can have a higher risk of adverse effects due to its interaction with other medications 5. Regular monitoring and careful patient selection are essential to minimize the risk of adverse effects.