90
Management
Figure 22. Treatment Algorithm for Pharmacological
Conversion of AF to Sinus Rhythm
Atrial fibrillation*
AF occurring
outside the
hospital in
patients with
normal LV function
("pill-in-the-
pocket")
†
HFrEF
(LVEF ≤40%)
Normal LV
function
Flecainide
Propafenone
(2a)
IV Amiodarone
(2a)
IV Amiodarone
‡
Ibutilide
‡
(2a)
Procainamide
(2b)
§
* In the absence of pre-excitation.
†
First dose should be administered in a facility that can provide continuous ECG
monitoring and cardiac resuscitation, due to the potential for proarrhythmia or post-
conversion bradycardia.
‡
Intravenous amiodarone requires several hours for efficacy; ibutilide is generally effective
in 30–90 minutes, but carries a higher risk of QT interval prolongation and torsades de
pointes.
§
Recommend avoidance of intravenous procainamide for patients initially treated with
amiodarone or ibutilide, to avoid excessive QT interval prolongation and torsades de
pointes; rather, procainamide may be considered for patients for whom amiodarone and
ibutilide are not considered optimal as first-line drugs.
