Unstable: synchronised cardioversion (≥ 200 J biphasic). Stable: treat triggers (sepsis, hypovolaemia, K+, Mg2+, catecholamines), then rate control with a beta-blocker or diltiazem if LVEF > 40%, or amiodarone/digoxin if LVEF ≤ 40% or hypotensive. Assess anticoagulation.
At the bedside
Timed steps- 1
Unstable?
0 minShock, ischaemia, acute HF or syncope caused by the arrhythmia: synchronised DC cardioversion, initial ≥ 200 J biphasic, under sedation.
- 2
Triggers
0-30 minSepsis, hypovolaemia, hypoxia, pain, K+ < 4 or Mg2+ low, high-dose catecholamines, thyrotoxicosis, PE, alcohol withdrawal, pericarditis. Correct K+ to 4-4.5 and give Mg 2 g IV.
- 3
LVEF > 40%
Rate controlMetoprolol 2.5-5 mg IV (repeat to 15 mg) or esmolol infusion, or diltiazem 0.25 mg/kg IV.
- 4
LVEF ≤ 40% or hypotension
Rate controlAmiodarone 300 mg IV over 1 h then 900 mg/24 h, or digoxin 0.5 mg IV then 0.25 mg 6-hourly (max 1-1.5 mg).
- 5
Lenient
TargetInitial heart rate target < 110/min; tighter only if symptoms persist.
- 6
Elective cardioversion
RhythmIf AF > 24 h and not anticoagulated: TOE to exclude LA thrombus or ≥ 3 weeks anticoagulation first.
- 7
Stroke risk
AnticoagulationCHA2DS2-VA ≥ 2: anticoagulate unless bleeding risk prohibitive; reassess new-onset sepsis-related AF after recovery.
Rate/rhythm control (reduced EF or hypotension)
Amiodarone
- Dose
- 300 mg over 1 h, then 900 mg over 24 h
- Preparation
- 300 mg in 50 mL D5 (6 mg/mL); 900 mg in 500 mL D5
Rate control (LVEF > 40%)
Metoprolol
- Dose
- 2.5-5 mg, repeat every 5 min, max 15 mg
Titratable rate control
Esmolol
- Dose
- 500 mcg/kg over 1 min, then 50-300 mcg/kg/min
- Preparation
- Undiluted 10 mg/mL
- Worked example
- 70 kg × 100 mcg/kg/min = 7 mg/min = 420 mg/h ÷ 10 = 42 mL/h
Rate control (LVEF > 40%)
Diltiazem
- Dose
- 0.25 mg/kg, then 5-15 mg/h
- Worked example
- 70 kg: 17.5 mg ≈ 3.5 mL of 5 mg/mL
Add-on rate control
Digoxin
- Dose
- 0.5 mg, then 0.25 mg every 6 h to total 1-1.5 mg
Calculators for this topic
AF with rapid rate
Step 1 of ~3
Decision: Haemodynamically unstable due to AF?
Based on Van Gelder IC, Rienstra M, Bunting KV, et al. Educational use; follow local protocol.
Evidence
- ESC AF 2024 (AF-CARE): beta-blockers, diltiazem/verapamil (LVEF > 40%) or digoxin for rate control; amiodarone for acute rate control in haemodynamic instability or severely reduced EF; lenient initial target < 110/min; CHA2DS2-VA for stroke risk; TOE or 3 weeks anticoagulation before cardioversion if AF > 24 h.
- AHA 2025: ≥ 200 J initial energy for AF cardioversion.
Controversies
- Anticoagulation for AF that occurs only during critical illness.
🇮🇳 India notes
- Rheumatic mitral stenosis is a common cause of AF in India; it is a 'valvular' AF where warfarin (not DOACs) is indicated.
References
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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.