Class I Drugs
Flecainide
1y Efficacy:30%-50%
Dosage:50-150 mg PO BID
Toxicity:
  • Ventricular tachycardia
  • Bradycardia
  • Rapid ventricular response to AF or atrial flutter (1:1 conduction)
Comments:
  • Contraindicated in patients with CAD or LV dysfunction
  • Should be combined with an AV nodal blocking agent
Propafenone
1y Efficacy:30%-50%
Dosage:150-300 mg PO TID
Toxicity:
  • Ventricular tachycardia
  • Bradycardia
  • Rapid ventricular response to AF or atrial flutter (1:1 conduction)
  • Abnormal taste
Comments:
  • Contraindicated in patients with CAD or LV dysfunction
  • Should be combined with an AV nodal blocking agent
Class III Drugs
Amiodarone
1y Efficacy:60%-70%
Dosage:100-200 mg PO Daily (after 10 g loading)
Toxicity:
  • Photosensitivity
  • Bradycardia
  • GI upset
  • Thyroid dysfunction
  • Hepatic toxicity
  • Neuropathy, tremor
  • Pulmonary toxicity
  • Torsades de pointes (rare)
Comments:
  • Low risk of proarrhythmia in a wide range of populations
  • Limited by systemic side effects
  • Most side effects are dose and duration related
  • Very effective for rate control
Dronedarone
1y Efficacy:40%
Dosage:PO 400 mg BID
Toxicity:
  • GI upset
  • Bradycardia
Comments:
  • Only antiarrhythmic shown to reduce hospitalizations and cardiovascular mortality in ATHENA trial
  • May increase mortality in patients with recently decompensated heart failure, EF <35% (ANDROMEDA trial)
  • Effective rate-control agent
  • New drug – limited experience outside trials
Sotalol
1y Efficacy:30-50%
Dosage:40-160 mg PO BID
Toxicity:
  • Torsades de pointes
  • Bradycardia
  • Beta-blocker side effects
Comments:
  • Should be avoided in patients at high risk of torsades de pointes VT - especially women aged >65 y taking diuretics or those with renal insufficiency
  • QT interval should be monitored 1 wk after starting
  • Use cautiously when EF <40%
  • Heart rhythm specialists may use with lower EFs if patient has ICD

ANDROMEDA, Antiarrhythmic Trial With Dronedarone in Moderate to Severe Congestive Heart Failure Evaluating Morbidity Decrease; ATHENA, A Placebo-Controlled Double-Blind, Parallel Arm Trial to Assess the Efficacy of Dronedarone 400 mg BID for the Prevention of Hospitalization or Death From Any Cause in Patients With Atrial Fibrillation/Flutter; AV, atrioventricular; CAD, coronary artery disease; EF, ejection fraction; ICD, implantable cardioverter defibrillator; LV, left ventricular; VT, ventricular tachycardia.