|Drug||Initial Daily Dose(s)||Maximum Total Daily Maintenance Dose||Potential Adverse Effects||Precautions (Exclude or Use With Caution) and Interactions|
|Atenolol||25–50 mg QD||100 mg QD|
(reduced dosing in patients with severe renal dysfunction)
|Hypotension, bronchospasm, bradycardia|
|Metoprolol tartrate||25 mg BID||200 mg BID||Hypotension, bronchospasm, bradycardia|
|Metoprolol succinate (long-acting)||50 mg QD||400 mg QD||Hypotension, bronchospasm, bradycardia|
|Nadolol||40 mg QD||320 mg QD|
(reduced dosage with renal impairment)
|Hypotension, bronchospasm, bradycardia|
|Propranolol||30–60 mg in divided or single dose with long-acting formulations||40–160 mg in divided or single dose with long-acting formulations||Hypotension, worsening HF, bronchospasm, bradycardia|
|Nondihydropyridine calcium channel antagonists|
|Diltiazem||120 mg daily in divided or single dose with long-acting formulations||360 mg daily in divided or single dose with long-acting formulations||Hypotension, worsening HF in patients with pre-existing ventricular dysfunction, bradycardia, abnormal liver function studies, acute hepatic injury (rare)|
|Verapamil||120 mg daily in divided or single dose with long-acting formulations||480 mg daily in divided or single dose with long-acting formulations||Hypotension, worsening HF in patients with pre-existing ventricular dysfunction, pulmonary edema in patients with hypertrophic cardiomyopathy, bradycardia, abnormal liver function studies|
|Digoxin||Loading: 0.5 mg, with additional 0.125–0.25-mg doses administered at 6–8-h intervals until evidence of adequate effect (maximum dose 8–12 mcg/kg over 24 h)||0.25 mg QD|
Maintenance: 0.125–0.25 mg QD, with dosing based on patient’s age, lean body weight, and renal function and drug interactions; occasionally down to 0.0625 mg in cases of renal impairment (trough serum digoxin level 0.5 to 1 ng/mL)
|Bradycardia, heart block, anorexia, nausea, vomiting, visual changes and cardiac arrhythmias in cases of digoxin toxicity (associated with levels >2 ng/mL, although symptoms may also occur at lower levels)|
|Class Ic antiarrhythmic agents|
|Flecainide||50 mg every 12 h||150 mg every 12 h|
(PR and QRS intervals should be monitored. May consider monitoring flecainide plasma levels, keeping trough plasma levels below 0.7–1.0 mcg/mL)
|Atrial flutter with 1:1 AV conduction‡, QT prolongation, torsades de pointes, worsening HF, bradycardia|
|Propafenone||150 mg every 8 h (immediate release);|
225 mg every 12 h (extended release)
|300 mg every 8 h (immediate release);|
425 mg every 12 h (extended release)
(PR and QRS interval should be monitored. Consider dosage reduction with hepatic impairment)
|Atrial flutter with 1:1 AV conduction‡, QT prolongation, torsades de pointes, bradycardia, bronchospasm|
|Class III antiarrhythmic agents|
|Amiodarone||400–600 mg QD in divided doses for 2-4 wk (loading dose); followed by 100–200 mg QD (maintenance dose)||Up to 1200 mg QD may be considered in an inpatient monitoring setting (loading dose); up to 200 mg QD maintenance (to minimize long-term adverse effects)||Bradycardia, QT prolongation, torsades de pointes (rare), gastrointestinal upset, constipation, hypothyroidism, hyperthyroidism, pulmonary fibrosis, hepatic toxicity, corneal deposits, optic neuritis, peripheral neuropathy, photosensitivity, adult respiratory distress syndrome after cardiac or noncardiac surgery (rare)|
|Dofetilide||Repeat ECG 2–3 h after administering the first dose to determine QTc; if the QTc increased by >15% compared with baseline or if QTc is >500 ms† (550 ms in patients with ventricular conduction abnormalities), subsequent dosing should be down titrated by 50%; at 2–3 h after each subsequent dose, determine QTc (for in-hospital doses 2–5); if at any time after the second dose the QTc is >500 ms‖ (550 ms in patients with ventricular conduction abnormalities), dofetilide should be discontinued||QT prolongation, torsades de pointes|
|Sotalol||40–80 mg every 12 h|
(Patients initiated or reinitiated on sotalol should be placed in a facility that can provide cardiac resuscitation and continuous electrocardiographic monitoring for a minimum of 3 d).
Contraindicated if the QTc† interval is >450 ms.
CrCl should be calculated before dosing. If CrCl >60 mL/min, then dosing frequency is twice daily. If CrCl 40-60 mL/min, dosing interval is every 24 h. If CrCl <40 mL/min, should not be used.)
|160 mg every 12 h|
(During initiation and titration, the QT interval should be monitored 2–4 h after each dose. If the QT interval prolongs to ≥500 ms, the dose must be reduced or the drug discontinued.)
|QT prolongation, torsades de pointes, bradycardia, bronchospasm|
|Ivabradine||5 mg BID||7.5 mg BID||Phosphenes, AF|
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; BP, blood pressure; CrCl, creatinine clearance; ECG, electrocardiogram/electrocardiographic; HF, heart failure; INR, international normalized ratio; LV, left ventricular; QD, once daily; QID, 4 times a day; QTc, corrected QT interval; SA, sinoatrial; SVT, supraventricular tachycardia; TID, 3 times a day; 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 and adverse reactions are not included in this list. For a more detailed list of drug interactions and adverse responses, clinicians should consult additional resources; for example, www.crediblemeds.org may be consulted for potential prolongation of the QT interval.
↵† QTc calculation used the Bazett’s Formula in most clinical studies.
↵‡ Recommended given in conjunction with a beta blocker or nondihydropyridine calcium channel antagonist.