›Up to 3 doses at 5-minute intervals
›Maximum 15 mg total
›Avoid in decompensated HF and severe asthma
›Selective beta-1 blockade still has risks in severe reactive airway disease
›Esmolol IV
›500 mcg/kg bolus over 1 minute
›Maintenance infusion 50-300 mcg/kg/min
›Titrate by 25-50 mcg/kg/min every 5-15 minutes
›Extremely short half-life 9 minutes
›Advantage for rapid dose adjustment
›Avoid in decompensated HF
Rate control — reduced EF or decompensated HF
›Amiodarone IV
›Dosing for rate control in HFrEF
›300 mg IV over 1 hour loading
›Maintenance 10-50 mg/h over 24 hours
›Oral transition when rate controlled
›Effective for both rate and rhythm control
›Use when other agents contraindicated
›QT prolongation monitoring required
›Digoxin IV
›Dosing
›0.25 mg IV, maximum 1.5 mg per 24 hours
›Slow onset 1-4 hours limits acute utility
›Most useful as adjunct to other agents
›Caution in renal impairment
›Dose reduction required eGFR <30 mL/min
›Narrow therapeutic index
›IV magnesium adjunct
›Magnesium sulfate 2 g IV over 10-20 minutes
›Reasonable adjunct to standard rate control
›Evidence from multiple small trials
›May reduce ventricular rate when added to diltiazem or beta-blocker
Rhythm control — cardioversion
›Timing and anticoagulation strategy
›AF duration <48 hours
›Cardioversion may proceed without TEE
›Anticoagulate before and continue 4 weeks post-conversion regardless of CHA2DS2-VASc
›Heparin IV or LMWH bridge if DOAC not yet at therapeutic level
›Electrical cardioversion success rate 92-96% for recent-onset AF
›AF duration >48 hours or unknown
›TEE to exclude LAA thrombus before cardioversion
›Or therapeutic anticoagulation >=3 weeks before cardioversion
›Followed by >=4 weeks anticoagulation post-conversion
›Class I recommendation, ACC/AHA 2023 guideline
›Pharmacologic cardioversion
›Flecainide or propafenone (pill-in-pocket strategy)
›Only if no structural heart disease
›Flecainide 200-300 mg PO single dose
›Propafenone 450-600 mg PO single dose
›Must have AV nodal blocking agent on board first
›Prevents 1:1 flutter conduction risk
›IV ibutilide
›1 mg IV over 10 minutes
›Repeat if no conversion at 10 minutes
›QT monitoring required for 4-6 hours post-dose
›Torsades de pointes risk 1-4%
›Avoid if QTc >440 ms at baseline
›Resuscitation equipment at bedside
›DOAC initiation
›Apixaban
›5 mg PO twice daily standard dose
›Reduce to 2.5 mg twice daily if >=2: age >=80, weight <=60 kg, Cr >=133 umol/l
›Class I recommendation for non-valvular AF
›Rivaroxaban
›20 mg PO once daily with evening meal
›Reduce to 15 mg daily if CrCl 15-49 mL/min
›Avoid if CrCl <15 mL/min
›Dabigatran
›150 mg PO twice daily standard dose
›Reduce to 110 mg twice daily if age >=80 or high bleeding risk
›Contraindicated if CrCl <30 mL/min
›Edoxaban
›60 mg PO once daily
›Reduce to 30 mg if CrCl 15-50 mL/min, weight <=60 kg, or certain P-gp inhibitors
›Warfarin indications
›Mechanical heart valves
›DOACs inferior to warfarin in this context
›INR target 2.5-3.5 for most mechanical valves
›Moderate-severe mitral stenosis
›Warfarin preferred over DOACs
›INR target 2-3
›Anticoagulation timing in ED
›Safe to initiate DOACs in ED
›Apixaban or rivaroxaban most commonly used
›Evidence supports ED initiation is safe
›Post-cardioversion anticoagulation minimum 4 weeks
›Regardless of CHA2DS2-VASc score
›Stunning phenomenon risk despite sinus rhythm restoration
›Heart rate targets
›Lenient rate control target
›HR <110 bpm at rest acceptable per RACE II trial
›Non-inferior to strict control for most patients
›Fewer medication side effects
›Strict rate control target
›HR <80 bpm at rest if symptoms persist at 110 bpm
›HR <110 bpm during moderate exertion
›Indicated when tachycardia-mediated cardiomyopathy suspected