Atrial fibrillation
Supraventricular tachyarrhythmia with uncoordinated atrial activation and an irregular ventricular response. Increases the risk of ischemic stroke.
ICD-10 I487 drugs
Also known as: AF, AFib, A-fib
Drugs used for this condition
- ABisoprololFirst line · Selective beta-adrenergic blockersBeta-blockers are first-line rate control agents in atrial fibrillation per ESC 2020. Bisoprolol is given to achieve a target resting HR below 110 bpm (lenient control) or below 80 bpm (strict control when indicated).
- BDofetilideSecond line · Class III antiarrhythmic, selective IKr blockerDofetilide is a second-line antiarrhythmic for sinus rhythm maintenance in atrial fibrillation when amiodarone failed or is contraindicated. ESC 2024 supports use in patients without heart failure. FDA REMS requires inpatient initiation with continuous ECG monitoring for the first 3 days.
- BFlecainideFirst line · Class Ic antiarrhythmicClass IC antiarrhythmic for pharmacological cardioversion of atrial fibrillation paroxysms and sinus rhythm maintenance in patients without structural heart disease. SEC uses the "pill-in-the-pocket" strategy for infrequent episodes.
- BPropafenoneSecond line · Class Ic antiarrhythmic with beta-blocking activityPropafenone is second-line antiarrhythmic for sinus rhythm maintenance in paroxysmal atrial fibrillation in patients WITHOUT structural heart disease. ESC 2024 supports the pill-in-the-pocket strategy (450–600 mg single dose during paroxysm). Contraindicated in coronary artery disease, LV dysfunction or heart failure.
- BSotalolSecond line · Non-selective beta blocker with class III antiarrhythmic activityClass III antiarrhythmic with β-blocking activity for sinus rhythm maintenance in atrial fibrillation. SEC uses sotalol as an amiodarone alternative in patients without significant structural disease.
- BWarfarinFirst line · Vitamin K antagonist anticoagulantsWarfarin reduces stroke risk in atrial fibrillation by 64 % compared to placebo. Target INR 2.0–3.0. Direct oral anticoagulants (DOACs) have largely replaced warfarin as first choice in non-valvular AF. Warfarin remains first-line in valvular AF, particularly with mitral stenosis or mechanical valves.
- CQuinidineThird line · Class Ia antiarrhythmic (sodium channel blocker with intermediate kinetics)Quinidine is a third-line antiarrhythmic for atrial fibrillation when amiodarone and dronedarone are contraindicated or ineffective. ESC 2024 explicitly moves quinidine to a reserve role because of sudden cardiac death risk, QT prolongation and torsades de pointes. Baseline renal and hepatic function, QTc, potassium and magnesium are required. ECG monitoring on days 1, 3 and 7.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit