CPJE Secrets 2026: Atrial Fibrillation and Antiarrhythmics

Antithrombotics for AF

Pradaxa (dabigatran)

Xarelto (rivaroxaban)

Eliquis (apixaban)

Coumadin (warfarin)

Aspirin alone shows little benefit in preventing stroke among patients with AF.

May also need rate control via BB, CCB, or digoxin

HF + AF: use nDHP CCBs (diltiazem, verapamil) only if EF normal

Use warfarin if mechanical valve!

Arrhythmia Types

Atrial Fibrillation (Afib, AF)

Atrial Flutter

Torsade de Pointes (TdP)

Antiarrhythmics treat this, but they also decrease heart rate, so avoid in unstable HF. Pacerone (amiodarone) and Tikosyn (dofetilide) are the exceptions.

When it comes to controlling rate vs. rhythm, it is easier and safer to control rate.

First-line rate control via:

Beta-blockers

Diltiazem/verapamil

Lanoxin (digoxin)

Antiarrhythmic Classes

Class Ia - Double Quarter Pounder

Prolong QT!

Disopyramide (Norpace)

Quinidine

Procainamide

Class Ib - Lettuce Mayo

Monitor liver function!

Lidocaine (Xylocaine)

Mexiletine (Mexitil)

Class Ic - Pepsi Fries

Used in patients w/ no/minimal structural heart disease (proarrhythmic!)

Propafenone

Flecainide

Class II - Beta Blockers

Esmolol (Brevibloc)

Propranolol (Inderal LA, InnoPran XL)

Class III - ADDIS

Amiodarone (Cordarone)

Dofetilide (Tikosyn)

Dronedarone (Multaq)

Ibutilide (Corvert)

Sotalol (Betapace)

Class IV - non-DHPs

Preferred over BB if asthma/COPD

Veralan, Calan (verapamil)

Cardizem (diltiazem)

Other

Adenocard (adenosine)

Lanoxin, Digitek (digoxin)

Drugs that Prolong QT

FQs, macrolides, amantadine, foscarnet, azoles

Protease inhibitors (saquinavir/ritonavir, atazanavir)

Antipsychotics, antidepressants

Antiemetics (5-HT3s)

Alfuzosin, apomorphine, chlorine, galantamine, methadone, pentamidine

Quinidine

Take w food to minimize GI upset

BBW: increased mortality, thrombocytopenia

Look for diarrhea, cinchonism

DDIs: digoxin, warfarin, grapefruit, verapamil, diltiazem, erythromycin (CYP inducer)

Procainamide

Take on empty stomach

BBW: agranulocytosis; monitor for DILE!

DIsopyramide

Norpace

Take on empty stomach.

Look for HF, anticholinergic effects; avoid if urinary retention, BPH, glaucoma, MG

Lidocaine

Xylocaine IV and endotracheal (higher dose!)

DDIs: amiodarone, BBs, CYP inhibitors

Mexiletine

Mexitil

ORAL, take with food!

Amiodarone

Cordarone, Pacerone IV and PO

A broad-spectrum antiarrhythmic safe in heart failure and post-MI, but should only be used for life-threatening arrhythmias. Dispensed with MedGuide.

Loading: 10g → 100-400mg QD. Half-life of 55 days (long).

Non-PVC/glass for infusions. D5W preparation only

Look for vision changes, corneal micro deposits, photosensitivity, hypotension, bradycardia, dizziness, tremor, slate blue skin

Monitor thyroid, liver, lungs

DDI: avoid QT prolonging drugs. Lower dose of digoxin, warfarin, quinidine, procainamide, Zocor, Mevacor, Lipitor. Cautionary use with BBs and nDHPs (can lead to bradycardia. Avoid grapefruit, SJW, ephedra.

Should take with food and water to avoid nausea and constipation.

Dofetilide

Tikosyn 500mcg BID, continuous hospital monitoring

Dronedarone

Multaq 400mg BID

BBW: heart failure

Preg. Cat X

Hep/renal failure

Ibutilide

Corvert IV only

Sotalol

Betapace 160mg BID

Look for bradycardia, hypotension, TdP, HF, dizziness

Adenosine

Adenocard 6mg IV push

Digoxin

Lanoxin, Digitek

AF Range: 0.8-2

HF Range: 0.5-0.9

Toxic: > 2.5

Angina (Chronic Chest Pain)

Goal: prevent attacks and risk of ACS

Combination of

Aspirin 81mg indefinitely (specify to chew if EC)

• Can use Plavix (clopidogrel) 75mg PO QD alternatively, still indefinite

AND

Antianginal Agents

Beta Blockers (CI: Prinzmetal’s Angina)

CCBs (1st line in Prinzmetal’s Angina) or as an add-on

Nitrates for immediate relief or as an add-on

IV Nitroglycerin

Tridil in D5W

HTN and ischemic emergencies.

5mcg/min, titratable to max 400mcg/min

Glass bottles only, PVC leads to adsorption. Use in NTG-specific sets.

Nitroglycerin Ointment

Nitro-Bid 2%

Angina prevention

1/2-2” to chest or back with applicator/dose paper. Max 2 dose/d.

Nitrate-free interval: 12 hours/d.

1/2” = 7.5mg

Nitroglycerin Patch

Nitro-Dur, Minitran

2.5, 5, 7.5, 10, 15mg patches

• 2.5mg = 0.1mg/h, delivered over 24 hours

• Titrate to 0.4-0.8 mg/h

Minimize tolerance by nitrate-free interval: 12 hours! Rotate patch sites.

Nitroglycerin Spray, Translingual

NitroMist, Nitrolingual 0.4mg/spray

1-2 sprays onto/under tongue every 5 minutes for 3 doses max. Do not shake container. Requires priming (Nitrolingual - 5 times, NitroMist - 10 times) and close mouth after administration.

Nitroglycerin Sublingual Tablet

Nitrostat 0.3-0.6mg every 5 minutes for 3 doses max in 15 minutes. Place under tongue.

No matter what, call 911 after dose 1.

Nitroglycerin Extended Release

Nitro-Time 2.5mg caps TID-QID up to 26mg QID

Isosorbide Mononitrate

Ismo, Monoket (IR) 5-60mg BID

Indur ER 10-120mg QD

Isosorbide Dinitrate

Mainly used for HF.

Isordil (IR) 5-40mg BID-TID

Dilatrate-SR 40mg QD-BID

SL: 2.5-5mg prior to activity (ppx), q5min max 3 dose if pill-in-pocket failure

BiDil (75mg hydralazine/40mg ISDN) 1 tablet TID; hydralazine leads to lower HF mortality

• Hydralazine = lupus symptoms (DILE)

Ranolazine

Ranexa 500mg BID to decrease oxygen demand

Add-on therapy. Can cause dizziness, constipation, QT.