Intravenous pharmacologic agents for acute heart rate control in patients with atrial fibrillation and chronic obstructive pulmonary disease*

Drug	Loading dose	Onset	Maintenance dose (for initial 24 to 72 hours)	Major side effects
There is evidence and/or general agreement that the following drugs are effective for acute heart rate control in patients with AF who do NOT have an accessory pathway or heart failure
Verapamil^¶	0.075 to 0.15 mg/kg (usually 5 to 10 mg/dose [maximum 10 mg]) IV over 2 to 3 minutes, may repeat dose in 15 to 30 minutes if inadequate response to initial dose	3 to 5 minutes		Hypotension, heart block, heart failure
Diltiazem^¶	0.25 mg/kg IV (average adult dose 20 mg) over 2 minutes, may repeat with a higher dose of 0.35 mg/kg IV (average adult dose 25 mg) in 15 to 30 minutes if inadequate response to initial dose	2 to 7 minutes	5 to 15 mg/hour IV infusion titrated according to ventricular heart rate	Hypotension, heart block, heart failure
Metoprolol^¶^Δ^◊	2.5 to 5 mg IV over 2 minutes; up to 3 doses (maximum 15 mg total) administered 5 to 10 minutes apart may be given	5 minutes		Hypotension, heart block, bradycardia, heart failure, bronchoconstriction
For acute heart rate control in patients with AF and an accessory pathway
Amiodarone^¶^§	150 mg IV over 30 minutes, followed by 1 mg/minute IV infusion for 6 hours, followed by 0.5 mg/minute IV infusion for 18 hours	1 to 30 minutes	0.5 mg/minute IV infusion for up to additional 48 hours	Hypotension, sinus bradycardia, heart block, QT prolongation, ventricular arrhythmias, pulmonary toxicity
For acute heart rate control in patients with AF and heart failure but not an accessory pathway
Digoxin^¶^¥^‡	0.25 mg IV every 2 hours, up to a total dose of 1.5 mg	15 to 30 minutes, peak effect in 1 to 5 hours	0.125 to 0.25 mg orally once a day	Digitalis toxicity, heart block, bradycardia
Amiodarone^¶^§	150 mg IV over 30 minutes, followed by 1 mg/minute IV infusion for 6 hours, followed by 0.5 mg/minute IV infusion for 18 hours	1 to 30 minutes	0.5 mg/minute IV infusion for up to additional 48 hours	Hypotension, sinus bradycardia, heart block, QT prolongation, ventricular arrhythmias, pulmonary toxicity

* For patients with hemodynamic instability due to atrial fibrillation, direct current cardioversion is the treatment of choice. For all patients with COPD and atrial fibrillation with a rapid ventricular response, correction of hypoxemia, acidosis, and other metabolic disturbances is recommended. Theophylline can increase the ventricular response, so dosing should be regulated to keep the serum level in the range of 8 to 12 mg/mL; discontinuation of the medication should be considered.
¶ Electrocardiographic (ECG or telemetry) and blood pressure monitoring should be continuously performed during initial loading dose and frequently (eg, every 4 hours) during maintenance intravenous dosing.
◊ Representative of the type of selective beta-1 blockers that could be used but similar drugs could be given in appropriate doses.
Δ Nondihydropyridine calcium channel antagonists (eg, verapamil, diltiazem) are preferred over metoprolol for heart rate control of atrial fibrillation in patients with COPD due to concerns about exacerbating bronchoconstriction.
§ Amiodarone can be useful when other measures are unsuccessful or contraindicated. For patients with an accessory pathway, intravenous amiodarone can be given if the rhythm cannot be converted or ablated and rate control is needed.
¥ There is evidence and/or general agreement that digoxin is effective in patients with heart failure but not an accessory pathway.
‡ Dosing shown is for normal renal function and normal body weight. Reduced doses are needed for renal insufficiency or low body weight. Refer to topic on "Method of digitalization".

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خرید پکیج

Intravenous pharmacologic agents for acute heart rate control in patients with atrial fibrillation and chronic obstructive pulmonary disease*