Lidocaine is NOT used to treat atrial fibrillation in humans
Lidocaine has no established role in the treatment of atrial fibrillation and is not recommended by any major cardiology guideline. The drug is conspicuously absent from all guideline-recommended pharmacological cardioversion protocols and antiarrhythmic drug tables for AF management 1.
Evidence from Guidelines
Recommended Agents for AF Cardioversion
The 2016 ESC Guidelines explicitly list the approved drugs for pharmacological cardioversion of AF: flecainide, propafenone, amiodarone, ibutilide, and vernakalant—lidocaine is not among them 1. The 2014 AHA/ACC/HRS Guidelines similarly recommend flecainide, dofetilide, propafenone, and IV ibutilide for pharmacological conversion, with no mention of lidocaine 1.
Lidocaine's Actual Indication
The 2010 AHA Advanced Cardiovascular Life Support Guidelines clarify that lidocaine is less effective than other agents for ventricular tachycardia and should be considered second-line therapy even for that indication—it has no role whatsoever in AF management 1.
Critical Contraindication
The 2006 ACC/AHA/ESC Guidelines explicitly state that IV lidocaine is contraindicated in patients with Wolff-Parkinson-White syndrome and AF with preexcitation, as it can facilitate antegrade conduction along the accessory pathway, potentially causing acceleration of ventricular rate, hypotension, or ventricular fibrillation 1.
Research Evidence Confirms Ineffectiveness
Human Studies Show No Benefit
A prospective, randomized, double-blind crossover trial in 20 patients with AF found that high-dose bolus lidocaine (1.5-2.5 mg/kg) was completely ineffective—0 of 20 patients converted to sinus rhythm 2. The 95% confidence interval for effectiveness was 0% to 14%, leading investigators to conclude that routine use of lidocaine for AF cardioversion is not warranted 2.
Animal Studies Are Not Translatable
While lidocaine showed 100% effectiveness in converting vagally-mediated AF in dogs under specific experimental conditions (alpha-chloralose anesthesia or direct vagal stimulation) 3, 4, these findings have no clinical applicability to human AF management. More concerning, a 2022 veterinary case series reported that lidocaine administration in dogs with supraventricular tachyarrhythmias resulted in ventricular arrhythmias, with one case degenerating into ventricular fibrillation and cardiac arrest 5.
What Should Be Used Instead
For Pharmacological Cardioversion
- Flecainide or propafenone (oral 200-300 mg or 450-600 mg respectively, or IV 1.5-2 mg/kg) for patients without structural heart disease or ischemic heart disease 1
- Amiodarone (5-7 mg/kg IV over 1-2 hours) for patients with heart failure or structural heart disease 1
- Vernakalant (3 mg/kg IV over 10 minutes) for recent-onset AF without severe heart failure or hypotension 1
For Rate Control
- Beta-blockers (metoprolol, esmolol) or non-dihydropyridine calcium channel blockers (diltiazem, verapamil) as first-line agents 1, 6
- Digoxin or amiodarone for patients with heart failure and reduced ejection fraction 1, 6
Clinical Bottom Line
Lidocaine has no role in AF management—it is ineffective for cardioversion in humans, potentially dangerous in certain AF subtypes (WPW), and is not mentioned in any contemporary AF treatment algorithm 1, 2. Use guideline-recommended agents based on patient comorbidities and hemodynamic stability.