Management of Atrial Fibrillation

Patient Selection for Digoxin

• The American College of Cardiology recommends digoxin over amiodarone in patients with unstable atrial fibrillation who have heart failure or left ventricular dysfunction, especially when there is no accessory pathway 1
• The administration of intravenous digoxin is recommended to control heart rate in patients with atrial fibrillation and heart failure who do not have an accessory pathway (Level of Evidence: B) 1
• Digoxin is effective in controlling resting heart rate in patients with atrial fibrillation and is indicated for patients with heart failure, left ventricular dysfunction, or sedentary individuals 1, 2

Contraindications for Digoxin

• Digoxin should not be used as the sole agent to control ventricular response rate in patients with paroxysmal atrial fibrillation 1
• Digoxin should not be used in patients with pre-excitation syndrome (can paradoxically accelerate ventricular response) 1, 3

Alternative Therapies

• Amiodarone intravenous may be useful for controlling heart rate in patients with atrial fibrillation when other measures are ineffective or contraindicated (Level of Evidence: C) 1, 3
• The American Heart Association suggests considering amiodarone intravenous when other treatments have failed or are contraindicated 1, 3

Combination Therapies

• The combination of digoxin with beta-blockers or non-dihydropyridine calcium channel blockers may be reasonable for controlling heart rate both at rest and during exercise 1
• The American College of Cardiology recommends evaluating the presence of heart failure or left ventricular dysfunction to determine the use of digoxin or other therapies 1, 2

Cardioversion

• The American Heart Association recommends considering electrical cardioversion as the first option in patients with unstable atrial fibrillation and significant hemodynamic compromise 4

Precautions with Amiodarone

• Amiodarone can cause asymptomatic hypotension and has potential toxicity including pulmonary fibrosis, liver damage, and proarrhythmia 2
• The American Heart Association warns that high-dose oral amiodarone loading can worsen hemodynamics in patients with recent decompensated heart failure or hypotension 2