Table 22.

Drugs for Pharmacological Conversion of AF to Sinus Rhythm

Drug	Route of Administration	Loading Dose	Maintenance Dose	Approximate Time to Conversion to Sinus Rhythm	Primary Route(s) of Elimination	Elimination Half-Life	Major Adverse Effects
Amiodarone	IV	5–7 mg/kg or 300 mg*	1200–3000 mg via continuous infusion over 24 h	8–12 h	Liver metabolism Biliary excretion	9–36 d	Bradycardia Hypotension QT prolongation Phlebitis TdP
Flecainide	Oral†	200 mg if <70 kg, 300 mg if >70 kg, single dose	N/A	3–8 h	Liver (70%) Kidney (30%)‡	12–27 h	Atrial flutter AV block Dizziness Dyspnea Exacerbation of HFrEF Headache Nausea QT prolongation VT Visual disturbances
Ibutilide	IV	≥60 kg: 1 mg over 10 min <60 kg: 0.01 mg/kg over 10 min If arrhythmia does not terminate within 10 min after the end of the first infusion, may administer a second dose, equal to the first dose.	N/A	30–90 min	Liver	2–12 h	Nonsustained VT QT prolongation TdP
Procainamide	IV	1 g over 30 min	2 mg/min continuous infusion over 1 h	30–60 min	Liver (16–33%) Kidney (50–65%)‡	3–4 h (parent) 7 h (NAPA)	Agranulocytosis AV block Exacerbation of HFrEF Hypotension Neutropenia QT prolongation Rash Thrombocytopenia TdP
Propafenone	Oral	450 mg if <70 kg, 600 mg if >70 kg, single dose	N/A	3–8 h	Liver	9 h	Atrial flutter AV block Dizziness Dyspnea Exacerbation of HFrEF Nausea Taste disturbances VT Visual disturbances

^*Some studies have administered intravenous amiodarone for 24 h followed by oral administration.

^†Flecainide is available in an intravenous dosage form in Europe.

^‡Percentage of a dose excreted unchanged in urine.

AV indicates atrioventricular; AF, atrial fibrillation; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; N/A, not applicable; NAPA, N-acetylprocainamide; TdP, torsades de pointes; and VT, ventricular tachycardia.