Atrial Fibrillation Prescription Templates: Comprehensive Management Across All Clinical Scenarios
I. ACUTE RATE CONTROL (Hemodynamically Stable Patients)
A. Preserved Left Ventricular Function (LVEF >40%)
First-line options include beta-blockers or non-dihydropyridine calcium channel blockers, with diltiazem achieving rate control faster than metoprolol. 1, 2, 3
Template 1: Diltiazem (Preferred for rapid control)
- Diltiazem 0.25 mg/kg IV over 2 minutes (typically 20-25 mg for average adult) 2, 3
- If inadequate response after 15 minutes: Diltiazem 0.35 mg/kg IV over 2 minutes 3
- Maintenance: Diltiazem infusion 5-15 mg/hour 3
- Target: Resting heart rate <110 bpm 1, 2
Template 2: Metoprolol
- Metoprolol 2.5-5 mg IV over 2 minutes 2, 3
- Repeat every 5-10 minutes up to 3 doses (maximum 15 mg) 2
- Transition to oral: Metoprolol 25-100 mg PO twice daily 1
- Target: Resting heart rate <110 bpm 1, 2
Template 3: Esmolol (for short-acting control)
- Esmolol 500 mcg/kg IV bolus over 1 minute 1, 3
- Maintenance: Esmolol infusion 50-200 mcg/kg/min 1
- Titrate every 5 minutes as needed 3
B. Reduced Left Ventricular Function (LVEF ≤40%)
Beta-blockers and/or digoxin are recommended; avoid diltiazem and verapamil due to negative inotropic effects. 1, 3
Template 4: Beta-blocker for Heart Failure
- Metoprolol succinate 12.5-25 mg PO daily (start low) 1
- Titrate slowly every 2 weeks to target dose 200 mg daily 1
- Alternative: Carvedilol 3.125 mg PO twice daily, titrate to 25 mg twice daily 1
Template 5: Digoxin (monotherapy or combination)
- Digoxin 0.25 mg IV loading dose 1, 3
- Maintenance: Digoxin 0.125-0.25 mg PO daily 1
- Adjust for renal function: CrCl <50 mL/min use 0.125 mg daily or every other day 1
- Target digoxin level: 0.5-0.9 ng/mL 4
Template 6: Combination Therapy (Beta-blocker + Digoxin)
- Metoprolol 25-50 mg PO twice daily PLUS Digoxin 0.125 mg PO daily 1
- Monitor for bradycardia with ambulatory ECG 1
C. Hemodynamically Unstable Patients
Immediate electrical cardioversion is required for patients with hypotension, ongoing chest pain, acute heart failure, or altered mental status. 2
Template 7: Emergency Cardioversion
- Synchronized DC cardioversion: 120-200 joules biphasic 1
- Sedation: Midazolam 2-5 mg IV and/or Propofol 0.5-1 mg/kg IV 1
- Have atropine 0.5-1 mg IV available for post-cardioversion bradycardia 1
Template 8: IV Amiodarone (if cardioversion delayed)
- Amiodarone 150 mg IV over 10 minutes 1, 3
- Maintenance: Amiodarone 1 mg/min for 6 hours, then 0.5 mg/min for 18 hours 1
- Total maximum 24-hour dose: 1000 mg 1
II. CHRONIC RATE CONTROL (Permanent AF)
A. LVEF >40%
Template 9: Beta-blocker Monotherapy
- Metoprolol succinate 50-200 mg PO daily 1
- Alternative: Atenolol 25-100 mg PO daily 1
- Alternative: Bisoprolol 2.5-10 mg PO daily 1
- Target: Resting heart rate <110 bpm (lenient control) 1, 2
Template 10: Diltiazem Monotherapy
Template 11: Verapamil Monotherapy
Template 12: Combination Therapy (if monotherapy fails)
- Metoprolol 50 mg PO twice daily PLUS Digoxin 0.125 mg PO daily 1
- Avoid combining beta-blockers with diltiazem/verapamil except under specialist supervision with ambulatory ECG monitoring 1
B. LVEF ≤40%
Template 13: Beta-blocker for HFrEF
- Carvedilol 3.125 mg PO twice daily, titrate to 25 mg twice daily 1
- Alternative: Metoprolol succinate 12.5-25 mg PO daily, titrate to 200 mg daily 1
- Alternative: Bisoprolol 1.25 mg PO daily, titrate to 10 mg daily 1
Template 14: Digoxin for HFrEF
- Digoxin 0.125 mg PO daily (no loading dose needed for chronic management) 1
- Reduce to 0.125 mg every other day if CrCl <50 mL/min 1
Template 15: Beta-blocker + Digoxin Combination
III. RHYTHM CONTROL: PHARMACOLOGICAL CARDIOVERSION
A. Structurally Normal Heart (No CAD, No LVH, LVEF >40%)
Template 16: Flecainide (Pill-in-the-Pocket)
- Flecainide 200-300 mg PO single dose 1
- Must establish safety in hospital first before home use 1
- CONTRAINDICATED in ischemic heart disease or structural heart disease 1
Template 17: Flecainide IV (In-hospital)
- Flecainide 1.5-2 mg/kg IV over 10 minutes (maximum 150 mg) 1
- Monitor QRS duration; stop if QRS widens >50% 1
Template 18: Propafenone (Pill-in-the-Pocket)
- Propafenone 450-600 mg PO single dose 1
- Must establish safety in hospital first 1
- CONTRAINDICATED in ischemic heart disease or structural heart disease 1
Template 19: Propafenone IV
B. Any Structural Heart Disease or CAD
Template 20: Amiodarone IV
- Amiodarone 5-7 mg/kg IV over 1-2 hours (typically 300-450 mg) 1
- Maintenance: Amiodarone 50 mg/hour continuous infusion up to 1000 mg total in 24 hours 1
- Expect delayed conversion (8-12 hours) 1
Template 21: Vernakalant IV (if available)
- Vernakalant 3 mg/kg IV over 10 minutes 1
- If no conversion after 15 minutes: Vernakalant 2 mg/kg IV over 10 minutes 1
- CONTRAINDICATED if: SBP <100 mmHg, recent ACS (<30 days), NYHA Class III-IV HF, QTc >440 ms, severe aortic stenosis 1
C. Reduced LVEF or Heart Failure
Template 22: Amiodarone (only safe option)
- Amiodarone 5-7 mg/kg IV over 1-2 hours 1, 3
- Maintenance: Amiodarone 50 mg/hour infusion 1
- Flecainide and propafenone are CONTRAINDICATED 1
IV. RHYTHM CONTROL: LONG-TERM MAINTENANCE
A. No Structural Heart Disease
Template 23: Flecainide Maintenance
Template 24: Propafenone Maintenance
- Propafenone 150-300 mg PO three times daily 1
- Maximum 900 mg/day 1
- Requires normal LVEF, no CAD, no LVH 1
B. Hypertension with LVH or CAD
Template 25: Amiodarone Maintenance
- Loading: Amiodarone 400-600 mg PO daily for 2-4 weeks 1
- Maintenance: Amiodarone 200 mg PO daily (lowest effective dose) 1
- Monitor thyroid function, liver function, pulmonary function every 6 months 1
Template 26: Sotalol
- Sotalol 80 mg PO twice daily 1
- Titrate every 3 days to maximum 160 mg twice daily 1
- CONTRAINDICATED if: QTc >450 ms, CrCl <50 mL/min (adjust dose), severe asthma 1
- Requires baseline and follow-up ECG monitoring for QT prolongation 1
C. Heart Failure (LVEF ≤40%)
Template 27: Amiodarone (only safe AAD)
- Loading: Amiodarone 400 mg PO daily for 4 weeks 1
- Maintenance: Amiodarone 200 mg PO daily 1
- All other antiarrhythmics are CONTRAINDICATED in HFrEF 1
V. STROKE PREVENTION: ANTICOAGULATION
A. CHA₂DS₂-VASc Score ≥2 (Men) or ≥3 (Women)
Direct oral anticoagulants (DOACs) are preferred over warfarin for stroke prevention. 2
Template 28: Apixaban
- Apixaban 5 mg PO twice daily 1
- Reduce to 2.5 mg PO twice daily if ≥2 of: age ≥80 years, weight ≤60 kg, serum creatinine ≥1.5 mg/dL 1
- AVOID if CrCl <15 mL/min 1
Template 29: Rivaroxaban
- Rivaroxaban 20 mg PO daily with evening meal 1, 5
- Reduce to 15 mg PO daily if CrCl 15-50 mL/min 5
- AVOID if CrCl <15 mL/min or on dialysis 5
Template 30: Edoxaban
- Edoxaban 60 mg PO daily 1
- Reduce to 30 mg PO daily if: CrCl 15-50 mL/min, weight ≤60 kg, or concomitant P-gp inhibitors 1
- AVOID if CrCl <15 mL/min or >95 mL/min 1
Template 31: Dabigatran
- Dabigatran 150 mg PO twice daily 1, 6
- Reduce to 110 mg PO twice daily if: age ≥80 years, CrCl 30-50 mL/min, or high bleeding risk 6
- Reduce to 75 mg PO twice daily if CrCl 15-30 mL/min 6
- AVOID if CrCl <15 mL/min or on dialysis 6
Template 32: Warfarin (if DOACs contraindicated)
- Warfarin 5 mg PO daily (initial dose; adjust based on INR) 1
- Target INR: 2.0-3.0 1
- Check INR every 2-4 weeks once stable 1
B. Renal Impairment Adjustments
Template 33: CrCl 30-50 mL/min
- Apixaban 5 mg PO twice daily (no adjustment unless meets dose reduction criteria) 1
- Rivaroxaban 15 mg PO daily 5
- Edoxaban 30 mg PO daily 1
- Dabigatran 110 mg PO twice daily 6
Template 34: CrCl 15-30 mL/min
- Apixaban 2.5 mg PO twice daily (if meets dose reduction criteria) 1
- Rivaroxaban 15 mg PO daily (observe closely for bleeding) 5
- Edoxaban 30 mg PO daily 1
- Dabigatran 75 mg PO twice daily 6
Template 35: CrCl <15 mL/min or Dialysis
VI. SPECIAL POPULATIONS
A. Pre-Excitation Syndrome (Wolff-Parkinson-White)
AV nodal blockers (beta-blockers, calcium channel blockers, digoxin) are CONTRAINDICATED as they can precipitate ventricular fibrillation. 2, 3
Template 36: Acute Management of Pre-excited AF
- Procainamide 15 mg/kg IV over 30-60 minutes 1
- Alternative: Ibutilide 1 mg IV over 10 minutes (may repeat once) 1
- If hemodynamically unstable: Immediate electrical cardioversion 2
B. Young Adults with Paroxysmal AF
Rhythm control is preferred over rate control in younger patients to prevent tachycardia-induced cardiomyopathy and maintain quality of life. 2
Template 37: Young Adult Initial Strategy
- Acute: Diltiazem 0.25 mg/kg IV for immediate rate control <110 bpm 2, 3
- Long-term: Flecainide 100 mg PO twice daily (if structurally normal heart) 1, 2
- Anticoagulation: Assess CHA₂DS₂-VASc; initiate DOAC if score ≥2 (men) or ≥3 (women) 2
- Consider early catheter ablation if AAD fails 2
C. Severely Symptomatic Permanent AF with HF Hospitalization
Template 38: AV Node Ablation + CRT
- Continue optimal medical therapy: Carvedilol 25 mg PO twice daily PLUS Digoxin 0.125 mg PO daily 1
- If inadequate symptom control despite maximal therapy: Refer for AV node ablation with cardiac resynchronization therapy (CRT) implantation 1
- This reduces symptoms, HF hospitalization, and mortality 1
D. Refractory Rate Control (Monotherapy Failure)
Template 39: Intensified Combination Therapy
- Metoprolol 100 mg PO twice daily PLUS Digoxin 0.125 mg PO daily 1
- Monitor with ambulatory ECG to avoid bradycardia 1
- If still inadequate: Consider AV node ablation with pacemaker implantation 1
VII. COMORBIDITY-SPECIFIC TEMPLATES
A. Hypertension + AF
Template 40: Rate Control + BP Management
- Metoprolol succinate 100 mg PO daily (dual benefit: rate control + BP lowering) 1
- Add: Lisinopril 10-40 mg PO daily or Losartan 50-100 mg PO daily (reduces AF recurrence) 1
- Target BP: <130/80 mmHg 1
B. Heart Failure + AF
Template 41: Comprehensive HFrEF + AF Management
- Carvedilol 25 mg PO twice daily (rate control + HF mortality benefit) 1
- Sacubitril/valsartan 49/51 mg PO twice daily, titrate to 97/103 mg twice daily 1
- SGLT2 inhibitor: Dapagliflozin 10 mg PO daily or Empagliflozin 10 mg PO daily (reduces HF hospitalization and AF burden) 1
- Spironolactone 25 mg PO daily (if LVEF <35%) 1
- Furosemide 20-80 mg PO daily as needed for congestion 1
- Anticoagulation: Apixaban 5 mg PO twice daily 1
C. Diabetes + AF
Template 42: Glycemic Control + AF Management
- Rate control: Metoprolol 50 mg PO twice daily 1
- Metformin 1000 mg PO twice daily (glycemic control reduces AF burden) 1
- SGLT2 inhibitor: Empagliflozin 10-25 mg PO daily (cardiovascular benefit + reduces AF recurrence) 1
- Target HbA1c: <7% 1
D. Obesity + AF
Template 43: Weight Management + Rate Control
- Metoprolol 50-100 mg PO twice daily 1
- Structured weight loss program targeting ≥10% weight reduction (reduces AF burden and recurrence) 1
- Consider referral for bariatric surgery if BMI >40 kg/m² 1
VIII. CRITICAL PITFALLS TO AVOID
Pitfall 1: Using AV Nodal Blockers in Pre-excitation
- NEVER use beta-blockers, calcium channel blockers, or digoxin in patients with delta waves on ECG or known WPW syndrome 2, 3
- This can cause ventricular fibrillation by allowing rapid conduction down the accessory pathway 2
- Use procainamide or ibutilide instead 1
Pitfall 2: Using Calcium Channel Blockers in HFrEF
- NEVER use diltiazem or verapamil in patients with LVEF ≤40% 1, 3
- Negative inotropic effects can precipitate acute decompensation 3
- Use beta-blockers and/or digoxin instead 1
Pitfall 3: Using Flecainide/Propafenone in Structural Heart Disease
- NEVER use flecainide or propafenone in patients with CAD, prior MI, LVH, or LVEF <40% 1
- Increased risk of proarrhythmia and sudden cardiac death 1
- Use amiodarone instead 1
Pitfall 4: Stopping Anticoagulation After Successful Cardioversion
- Continue anticoagulation indefinitely if CHA₂DS₂-VASc score ≥2 (men) or ≥3 (women), even if sinus rhythm is restored 2
- Silent AF recurrences still cause thromboembolic events 2
- Majority of strokes occur after warfarin discontinuation 7
Pitfall 5: Inadequate Renal Dose Adjustment
- Always calculate CrCl and adjust DOAC doses accordingly 5, 6
- Failure to reduce doses in renal impairment increases bleeding risk 5, 6
- Avoid all DOACs if CrCl <15 mL/min; use warfarin instead 5, 6
Pitfall 6: Combining Beta-blockers with Diltiazem/Verapamil Without Monitoring
- Only combine under specialist supervision with ambulatory ECG monitoring 1
- High risk of severe bradycardia and heart block 1
Pitfall 7: Ignoring Tachycardia-Induced Cardiomyopathy
- Sustained RVR (>110 bpm) for weeks-months can cause reversible LV dysfunction 2
- Monitor LVEF; dysfunction improves within 6 months of adequate rate/rhythm control 2
- Aggressive rate control is essential to prevent permanent damage 2
IX. ANTICOAGULATION REVERSAL (Bleeding Emergencies)
A. DOAC Reversal
Template 44: Dabigatran Reversal
- Idarucizumab 5 g IV (two 2.5 g doses given consecutively) 1, 6
- Specific reversal agent for dabigatran 6
- Hemodialysis can remove 49-57% of dabigatran over 4 hours if idarucizumab unavailable 6
Template 45: Factor Xa Inhibitor Reversal (Rivaroxaban, Apixaban, Edoxaban)
- Andexanet alfa 400-800 mg IV bolus followed by 480-960 mg IV infusion over 2 hours 1
- If andexanet unavailable: Prothrombin complex concentrate (PCC) 50 units/kg IV 1
B. Warfarin Reversal
Template 46: Major Bleeding on Warfarin
- Vitamin K 10 mg IV slow infusion 1
- Prothrombin complex concentrate (PCC) 25-50 units/kg IV 1
- Alternative: Fresh frozen plasma 15 mL/kg IV (if PCC unavailable) 1
X. CARDIOVERSION ANTICOAGULATION PROTOCOLS
A. AF Duration <48 Hours
Template 47: Early Cardioversion
- Initiate DOAC immediately (e.g., apixaban 5 mg PO twice daily) 1
- Proceed with cardioversion (electrical or pharmacological) 1
- Continue anticoagulation for at least 4 weeks post-cardioversion 1
- If CHA₂DS₂-VASc ≥2 (men) or ≥3 (women): Continue anticoagulation indefinitely 1, 2
B. AF Duration ≥48 Hours or Unknown Duration
Template 48: Delayed Cardioversion Strategy
- Initiate DOAC (e.g., rivaroxaban 20 mg PO daily) 1
- Continue anticoagulation for 3 weeks before cardioversion 1
- Perform cardioversion 1
- Continue anticoagulation for at least 4 weeks post-cardioversion 1
- If CHA₂DS₂-VASc ≥2 (men) or ≥3 (women): Continue anticoagulation indefinitely 1
Template 49: TEE-Guided Early Cardioversion
- Initiate DOAC immediately 1
- Perform transesophageal echocardiogram (TEE) to exclude left atrial thrombus 1
- If no thrombus: Proceed with cardioversion 1
- Continue anticoagulation for at least 4 weeks post-cardioversion 1
- If CHA₂DS₂-VASc ≥2 (men) or ≥3 (women): Continue anticoagulation indefinitely 1