Table 2.
Common Medications Used in the Treatment of Atrial Fibrillation
| Rhythm Control Strategy | Usual Dose | Treatment Notes |
|---|---|---|
| Amiodarone | Initial load is 10 g Maintenance dose is 200 to 400 mg daily | Effective for multiple types of arrhythmias; very slowly metabolized and excreted; multiple side effects which include pulmonary, hepatic, and thyroid fibrosis. |
| Sotalol | 80 to 160 mg twice daily | Prolongs QT interval and requires monitoring; contraindicated with reduced ejection fraction or left ventricular hypertrophy; useful in patients with coronary artery disease |
| Rate Control Strategy | ||
| Beta-adrenergic blocking agents | Can worsen asthma, hypoglycemia unawareness, erectile dysfunction | |
| Metoprolol | 25 to 100 mg twice daily | Most commonly used beta-blocker, available in an extended release formula |
| Carvedilol | 3.125 mg to 25 mg twice daily | Effective antihypertensive; also indicated for heart failure with reduced ejection fraction |
| Calcium channel blockers (Nondihydropyridine) | Should be avoided in heart failure with reduced ejection fraction | |
| Diltiazem | 120 to 420 mg daily (controlled/extended release) | Also useful for hypertension and angina; immediate release formula requires dosing every 6–8 hr |
| Other | ||
| Digoxin | 0.0625 to 0.25 mg daily | Most useful in combination with beta-blockers; requires monitoring with blood level testing; toxicity possible, particularly in hypokalemia; must reduce dose in patients with kidney disease |
| Anticoagulation | ||
| Conventional | ||
| Aspirin | 81 to 325 mg daily | Mostly ineffective for stroke prevention; use only for patients at very high risk of bleeding |
| Warfarin (Coumadin) | 0.5 to 10 mg daily | Very narrow therapeutic window; requires obtaining frequent blood samples and involves dose adjustments; multiple drug and diet interactions |
| Direct Oral Anticoagulants | Not to be used in prosthetic heart valves or mitral stenosis; does not need monitoring; generics not available; minimal drug interactions; reduce dose in patients with kidney disease; drugs are more equivalent than different | |
| Apixaban (Eliquis) | 2.5 to 5 mg twice daily | Lowest risk of bleeding; increases diltiazem blood levels by 40% |
| Dabigatran (Pradaxa) | 75 to 150 mg twice daily | Lowest risk of stroke; occasionally causes dyspepsia; reversal agent available |
| Rivaroxaban (Xarelto) | 15 to 20 mg daily | Should be taken with food |