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Cardioversion upto7 Days

Drug	Class of Recommendation/ Level of Evidence	Dosage
Agents with proven efficacy
Dofetilide	I A	Creatinine clearance(ml/min) Dose (mg) >60 500 40 to 60 250 20 to 40 125 <20 Contraindicated
Flecainide	I A	Oral: 200 to 300 mg Intravenous: 1.5 to 3.0 mg/kg over 10 to 20 min
Ibutilide	I A	1 mg over 10 min; repeat 1 mg when necessary
Propafenone	I A	Oral: 600 mg Intravenous: 1.5 to 2.0 mg/kg over 10 to 20 min
Amiodarone	IIa A	Oral: Inpatient: 1.2 to 1.8 g per day in divided dose until 10 g total then 200 to 400 mg per day maintenance or 30 mg/kg as single dose Outpatient: 600 to 800 mg per day divided dose until 10 g total then 200 to 400 mg per day maintenance. Intravenous: 5 to 7 mg/kg over 30 to 60 min then 1.2 to 1.8 g per day continuous IV or in divided oral doses until 10 g total then 200 to 400 mg per day maintenance.

Cardioversion after 7 Days

Drug	Dosage
Dofetilide (I A)	Creatinine clearance(ml/min) Dose (mg) >60 500 40 to 60 250 20 to 40 125 <20 Contraindicated
Amiodarone (IIa A)	Oral: Inpatient: 1.2 to 1.8 g per day in divided dose until 10 g total then 200 to 400 mg per day maintenance or 30 mg/kg as single dose Outpatient: 600 to 800 mg per day divided dose until 10 g total then 200 to 400 mg per day maintenance. Intravenous: 5 to 7 mg/kg over 30 to 60 min then 1.2 to 1.8 g per day continuous IV or in divided oral doses until 10 g total then 200 to 400 mg per day maintenance.
Ibutilide (IIa A)	1 mg over 10 min; repeat 1 mg when necessary

Drugs which enhance the efficacy of cardioversion when given prior to the procedure: (Level of recommendation: IIa B)

• Amiodarone
• Flecainide
• Ibutilide
• Propafenone
• Sotalol

Drug Dosages for Maintenance of Sinus Rhythm

Following table summarizes the list of most commonly used drugs and their dosages for maintenance of sinus rhythm:

Drug	Dose
Amiodarone	100 to 400 mg
Disopyramide	400 to 750 mg
Dofetilide	5000 to 1000 mcg
Flecainide	200 to 300 mg
Procainamide	1000 to 4000 mg
Propafenone	450 to 900 mg
Quinidine	600 to 1500 mg
Sotalol	160 to 320 mg

Pharmacological Agents for Heart Rate Control

Drug	Class/LOE Recommendations	Loading Dose	Maintenance Dose
Acute Setting
Heart rate control in patients without accessory pathway
Esmolol	I C	500 mcg/kg IV over 1 min	60 to 200 mcg/kg/min IV
Propanolol	I C	0.15 mg/kg IV	NA
Metoprolol	I C	2.5 to 5 mg IV bolus over 2 min; up to 3 doses	NA
Diltiazem	I B	0.25 mg/kg IV over 2 min	5 to 15 mg/h IV
Verampil	I B	0.075 to 0.15 mg/kg IV over 2 min	NA
Heart Rate Control in patients with accessory pathway
Amiodarone	IIa C	150 mg over 10 min	0.5 to 1 mg/min IV
Heart Rate Control in patients with heart failure and without accessory pathway
Digoxin	I B	0.25 mg IV each 2 h, up to 1.5 mg	0.125 to 0.375 mg daily IV or orally
Amiodarone	IIa C	150 mg over 10 min	0.5 to 1 mg/min IV
Non-Acute Setting and Chronic Maintenance Therapy
Heart rate control
Metoprolol	I C	Same as maintenance dose	25 to 100 mg twice a day, orally
Propanolol	I C	Same as maintenance dose	80 to 240 mg daily in divided doses, orally
Verampil	I B	Same as maintenance dose	120 to 360 mg daily in divided doses; slow release available, orally
Diltiazem	I B	Same as maintenance dose	120 to 360 mg daily in divided doses; slow release available, orally
Heart Rate Control in patients with heart failure and without accessory pathway
Digoxin	I C	0.5 mg by mouth daily	0.125 to 0.375 mg daily, orally
Amiodarone	IIb C	800 mg daily for 1 wk, orally 600 mg daily for 1 wk, orally 400 mg daily for 4 to 6 wk, orally	200 mg daily, orally

CHADS₂Scoring for Predicting Risk of Stroke

	Condition	Points
C	Congestive heart failure	1
H	Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)	1
A	Age >/=75 years	1
D	Diabetes Mellitus	1
S2	Prior Stroke or TIA	2

Score	Risk	Anticoagulation Therapy	Considerations
0	Low	Aspirin	Aspirin daily
1	Moderate	Aspirin or Warfarin	Aspirin daily or INR to 2.0-3.0, depending on factors such as patient preference
2 or greater	Moderate or High	Warfarin	INR to 2.0-3.0, unless contraindicated (e.g. clinically significant GI bleeding, inability to obtain regular INR screening)

Anticoagulation is recommended for 3 wk prior to and 4 wk after cardioversion for patients with AF of unknown duration or with AF for longer than 48 h. When acute AF produces hemodynamic instability in the form of angina pectoris, MI, shock, or pulmonary edema, immediate cardioversion should not be delayed to deliver therapeutic anticoagulation, but intravenous unfractionated heparin or subcutaneous injection of a low-molecular-weight heparin should be initiated before cardioversion by direct-current countershock or intravenous antiarrhythmic medication.

Risk Factors for Stroke and Recommended Antithrombotic Therapy

Low Risk Factors	Moderate Risk Factors	High Risk Factors
Female gender	Age ≥ 75 years	Previous stroke, TIA or embolism
Age 65-74 years	Hypertension	Mitral stenosis
Coronary artery disease	Heart failure	Prosthetic heart valve
Thyrotoxicosis	LV ejection fraction ≤ 35%	-
-	Diabetes mellitus	-

Risk Category	Recommended Therapy
No risk factors	Aspirin, 81-325 mg daily
1 Moderate risk factor	Aspirin, 81-325 mg daily or Warfarin (INR 2.0 to 3.0, target 2.5)
Any high risk factor or more than 1 moderate risk factor	Warfarin (INR 2.0 to 3.0, target 2.5)*