Table 3.
Advised AADs and agents for various heart rhythm disorders based on clinical practice guidelines
| First-choice AAD | Strength of advice | Second-choice AAD | Strength of advice | ESC guideline (year/topic) | |
|---|---|---|---|---|---|
| Tachycardia prevention | |||||
| Sinus tachycardiaa | Ivabradine or β-blockers | Medium | Alternative or combined | Medium | 2019 SVT |
| AT focal | β-blockers, CCBs, or Ic | Medium | alternative | 2019 SVT | |
| AFL | β-blockers or CCBsb | Medium | Amiodaronec | Low | 2019 SVT |
| AF—no SHD or HF | Ic or dronedarone | High | Alternative | 2024 AF | |
| AF—SHD or HFpEF/HFmrEF | Dronedarone | High | Alternative | 2024 AF | |
| AF—HFrEF | Amiodarone | High | 2024 AF | ||
| PSVT—non pre-excited | β-blockers or CCBs | Mediumd | Alternative | Medium | 2019 SVT |
| PVT/VF SHD or ischaemia | β-blockers and K+/Mg2+ repletion | High | Amiodarone | Medium | 2022 VA |
| PVCs/VT idiopathic from outflow tract or fascicular | β-blockers or CCBs or Ic | Mediumd | Alternative | 2022 VA | |
| PVCs/VT idiopathic from other origin | β-blockers or CCBs | High | Alternative or ablation | 2022 VA | |
| VT SHD | β-blockers | Highe | Amiodarone or sotalol | Medium | 2022 VA |
| TdP/VF non-SHD | Nadolol/propranolol (LQTS 1 and 2, CPVT) Mexiletine (LQTS 3) Quinidine (SQTS, idiopathic VF, ERS, Brugada) |
High and Medium | Flecainide (CPVT) | Medium | 2022 VA |
| Tachycardia termination control | |||||
| AT focal | Adenosine i.v. | Medium | CCBs i.v. β-blockers i.v. |
Medium | 2019 SVT |
| AFL | Ibutilide/dofetilide i.v. | High | Amiodarone | Low | 2019 SVT |
| AFL (HR control) | β-blockers or CCBsb | Medium | Amiodaronec | Low | 2019 SVT |
| AF—no SHD/HF | Vernakalant i.v.f or flecainide/propafenone i.v. or PITP |
High | Alternative Ibutilideg |
2024 AF | |
| AF—SHD/HF | Vernakalant i.v.f or amiodarone i.v. |
High | Alternative | 2024 AF | |
| AF—no SHD or HF (HR control) | β-blockers, CCBs, or digoxinh | High | Alternative | 2024 AF | |
| AF—SHD or HF (HR control) | β-bockers or digoxin | High | Alternative | 2024 AF | |
| Narrow QRS T | Adenosine i.v.i | High | CCBs i.v. β-blockers i.v. |
Medium | 2019 SVT |
| Wide QRS T | Adenosine i.v. | High | Procainamide i.v. | Medium | 2019 SVT |
| SVT—Pre-excited | Ic or ibutilide or procainamide i.v.i | Medium | Alternative | 2019 SVT | |
| AF—Pre-excited | Ibutilide or procainamide i.v. | Medium | Ic | Low | 2019 SVT |
| PVCs/VT idiopathic from outflow tract or fascicular | β-blockers (outflow tract) or CCBs (fascicular) i.v. | High | Alternative | 2022 VA | |
| VT SHD or unknown | Procainamide i.v.j | Medium | Amiodarone | Low | 2022 VA |
| TdP/VFj non-SHD | Mg2+, K+, β-blockers (congenital LQTS) Isoprenaline (acquired LQTS, idiopathic VF, ERS, Brugada) Verapamil, Quinidine (idiopathic VF) |
High Medium |
2022 VA | ||
| PVT/VFj SHD or ischaemia | β-blockers and K+/Mg2+ repletion | High | Amiodarone | Medium | 2022 VA |
Alternative, the second alternative AAD is advised to be used when two options are offered.
Abbreviations: AADs, anti-arrhythmic drugs; AF, atrial fibrillation; AFL, atrial flutter; AT, atrial tachycardia; CCB, calcium channel blockers; CPVT, catecholaminergic PVT; ERS, early repolarization syndrome; HF, heart failure; HFpEF/HFmrEF/HFrEF, HF with preserved/mildly reduced/reduced left ventricle ejection fraction; HR, heart rate; LQTS, long QT syndrome; PITP, pill-in-the-pocket; PVC, premature ventricular contraction; PVT, polymorphic VT; SHD, structural heart disease; SVT, supraventricular tachycardia; TdP, torsades de pointes; VA, ventricular arrhythmias; VF, ventricular fibrillation; VT, ventricular tachycardia.
aThe treatment of reversible causes is the first-line option.
bUsed for HR control with little effect on AFL prevention.
cSotalol and dofetilide are also recommended in the 2023 AHA/ACC/HRS AF guidelines, with dronedarone identified as another reasonable alternative to amiodarone in this consensus.
dCatheter ablation is advised as the first-line option.
eβ-Blockers are advised as a first-line option to treat HF but have low efficacy to prevent sustained episodes of VT in this setting.
fVernakalant can be given to patients with SHD but no severe aortic stenosis, recent ACS or moderate-to-severe HF.
gIn geographies with no access to vernakalant or to i.v. type Ic drugs advised by the 2023 AHA/ACC/HRS AF guidelines.
hMay have limited efficacy if high adrenergic tone.
iVagal manoeuvres are the first-line option.
jElectrical cardioversion is the first-line option.