|Drug||Initial Dose||Subsequent or Maintenance Dose||Potential Adverse Effects||Precautions (Exclude or Use With Caution) and Interactions|
|Adenosine||6-mg rapid IV bolus (injected into IV as proximal or as close to the heart as possible), administered over 1–2 s, followed by rapid saline flush||If no result within 1–2 min, 12-mg rapid IV bolus; can repeat 12-mg dose 1 time. The safe use of 18-mg bolus doses has been reported (117).||Transient AV block, flushing, chest pain, hypotension, or dyspnea, AF can be initiated or cause decompensation in the presence of pre-excitation, PVCs/ventricular tachycardia, bronchospasm (rare), or coronary steal. Minor side effects are usually transient because of adenosine’s very short half-life.|
|Esmolol||500-mcg/kg IV bolus over 1 min||Infusion at 50–300 mcg/kg/min, with repeat boluses between each dosing increase||Hypotension, worsening HF, bronchospasm, bradycardia|
|Metoprolol tartrate||2.5–5.0-mg IV bolus over 2 min||Can repeat 2.5- to 5.0-mg IV bolus in 10 min, up to 3 doses||Hypotension, worsening HF, bronchospasm, bradycardia|
|Propranolol||1 mg IV over 1 min||Can repeat 1 mg IV at 2-min intervals, up to 3 doses||Hypotension, worsening HF, bronchospasm, bradycardia|
|Nondihydropyridine calcium channel antagonists|
|Diltiazem||0.25-mg/kg IV bolus over 2 min||Infusion at 5–10 mg/h, up to 15 mg/h||Hypotension, worsening HF in patients with pre-existing ventricular dysfunction, bradycardia, abnormal liver function studies, acute hepatic injury (rare)|
|Verapamil||5–10-mg (0.075–0.15-mg/kg) IV bolus over 2 min||If no response, can give an additional 10 mg (0.15 mg/kg) 30 min after first dose; then infusion at 0.005 mg/kg/min||Hypotension, worsening HF in patients with pre-existing ventricular dysfunction, pulmonary edema in patients with hypertrophic cardiomyopathy, bradycardia|
|Digoxin||0.25–0.5-mg IV bolus||Can repeat 0.25-mg IV bolus, up to maximum dose of 1.0 mg over 24 h (i.e., maximum loading dose 8–12 mcg/kg), given at 6–8-h intervals; maintenance dose based on patient’s age, lean body weight, renal function, and concomitant drugs (IV 2.4–3.6 mcg/kg/d)||Anorexia, nausea, vomiting, visual changes and cardiac arrhythmias if digoxin toxicity (associated with levels >2 ng/mL, although symptoms may also occur at lower levels)|
|Class III antiarrhythmic agents|
|Amiodarone||150 mg IV over 10 min||Infusion at 1 mg/min (360 mg) over next 6 h; then 0.5 mg/min (540 mg) over remaining 18 h||Hypotension, bradycardia, phlebitis, QT prolongation, torsades de pointes (rare), increased INR|
|Ibutilide||Contraindicated when QTc >440 ms‡; 1 mg over 10 min (if ≥60 kg); if <60 kg, then 0.01 mg/kg||Can repeat 1 mg once, if the arrhythmia does not terminate within 10 min§||QT prolongation, torsades de pointes, AV block|
Note: For this reference table, drugs are presented in alphabetical order within the drug classes, not by COR and LOE.
AF indicates atrial fibrillation; AV, atrioventricular; BID, twice daily; COR, Class of Recommendation; HF, heart failure; INR, international normalized ratio; IV, intravenous; LOE, Level of Evidence; LV, left ventricular; PVC, premature ventricular contraction; QTc, corrected QT interval; SA, sinoatrial; SVT, supraventricular tachycardia; and WPW, Wolff-Parkinson-White.
↵∗ When 1 drug is used in combination with other drugs, appropriate dosing adjustments should be made with consideration of at least additive effects during dosage titration. All potential drug–drug interactions are not included in this list. For a more detailed list of drug–drug interactions, clinicians should consult additional resources.
↵† If hypotension is a consideration, a slow infusion of diltiazem (2.5 mg/min) or verapamil (1 mg/min) for up to 20 minutes may lessen the potential for hypotension (92).
↵‡ QTc calculation used the Bazett’s Formula in most clinical studies. Patients should be observed with continuous ECG monitoring for at least 4 h after infusion or until QTc has returned to baseline.
↵§ The infusion should be stopped as soon as the arrhythmia is terminated or in the event of sustained or nonsustained ventricular tachycardia or marked prolongation of QT or corrected QT interval.