Treatment
26
Table 22. WPW and Pre-Excitation Syndromes
Recommendations COR LOE
Prompt direct-current cardioversion is recommended for
patients with AF, WPW, and RVR who are hemodynamically
compromised.
I C
Intravenous procainamide or ibutilide to restore sinus rhythm
or slow the ventricular rate is recommended for patients
with pre-excited AF and RVR who are not hemodynamically
compromised.
I C
Catheter ablation of the accessory pathway is recommended
in symptomatic patients with pre-excited AF, especially if the
accessory pathway has a short refractory period that allows
rapid antegrade conduction.
I C
Administration of intravenous amiodarone, adenosine,
digoxin (oral or intravenous), or nondihydropyridine calcium
channel antagonists (oral or intravenous) in patients with
WPW syndrome who have pre-excited AF is potentially
harmful because these drugs accelerate the ventricular rate.
III: Harm B
Table 23. Heart Failure
Recommendations COR LOE
Control of resting heart rate using either a beta blocker
or a nondihydropyridine calcium channel antagonist is
recommended for patients with persistent or permanent AF
and compensated HFpEF.
I B
In the absence of pre-excitation, intravenous beta-blocker
administration (or a nondihydropyridine calcium channel
antagonist in patients with HFpEF) is recommended to
slow the ventricular response to AF in the acute setting,
with caution needed in patients with overt congestion,
hypotension, or HF with reduced LVEF.
I B
In the absence of pre-excitation, intravenous digoxin or
amiodarone is recommended to control heart rate acutely in
patients with HF.
I B
Table 21. Pulmonary Disease
Recommendations COR LOE
A nondihydropyridine calcium channel antagonist is
recommended to control the ventricular rate in patients with
AF and chronic obstructive pulmonary disease.
I C
Direct-current cardioversion should be attempted in patients
with pulmonary disease who become hemodynamically
unstable as a consequence of new onset AF.
I C
