Rate control FA:

 Acute control with beta blockers 

 Metoprololo: is given as an intravenous bolus of 2.5 to 5.0 mg over two minutes. The dose may
be repeated at five-minute intervals up to a total of 15 mg as needed. While subsequent doses
can be given intravenously, the optimal regimen is not well defined, and oral administration is
preferable
 Esmololo: is a rapidly acting intravenous beta blocker that is metabolized by red blood cell
esterase, resulting in a short duration of action (10 to 20 minutes) [10-12]. Esmolol may be
particularly useful if it is uncertain that a beta blocker will be tolerated, since its short half-life
permits a therapeutic trial to be performed at reduced risk. If esmolol is tolerated, then a long-
acting beta blocker can be given. The following esmolol regimen is recommended for acute rate
control:
- A bolus of 0.5 mg/kg is infused over one minute, followed by 50 µg/kg per min.
- If, after four minutes, the response is inadequate, another bolus is given followed by an
infusion of 100 µg/kg per min.
- If, after four minutes, the response is still inadequate, a third and final bolus can be given
followed by an infusion of 150 µg/kgper min.
- If necessary, the infusion can be increased to a maximum of 200 µg/kg per min after another
four minutes.
- Alternatively, an infusion can be started at 50 µg/kg per min without a bolus, and the rate of
administration can be increased by 50 µg/kgper min every 30 minutes.
 Bisoprololo: ???
 Acute control with calcium channel blockers — We prefer intravenous diltiazemto
intravenous verapamil.
- Verapamil can be given acutely in a dose of 5 to 10 mg IV over two to three minutes; this
dose can be repeated every 15 to 30 minutes, as necessary. Once rate control is achieved
with intravenous bolus (often one or two are necessary), we start a maintenance infusion at a
rate of 5 mg/hour; higher infusion rates, perhaps up to 20 mg per hour, may be necessary for
rate control [31,32]. The onset of action is within two minutes and the peak effect occurs in
10 to 15 minutes. Control of the ventricular response is lost in approximately 90 minutes if
repeated boluses or a maintenance infusion are not given.
- Diltiazem is given as an intravenous bolus of 0.25 mg/kg (average adult dose 20 mg) over
two minutes; in 15 minutes, if the first dose is tolerated but does not produce the desired
response (20 percent reduction in heart rate from the baseline or a heart rate less than or
equal to 100 beats/min) a second bolus of 0.35 mg/kg (average adult dose 25 mg) is given
over two minutes; in those who respond to the first or second bolus, a continuous infusion at
a rate of 5 to 15 mg/h is initiated. This regimen usually controls the ventricular rate within
four to five minutes.