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AF with decompensated HF — MRCEM SBA MCQ

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HardCardiologyAF with decompensated HFMRCEM SBAMRCP Part 1UKMLAPARAPSA

A 60-year-old man presents with newly diagnosed atrial fibrillation at a ventricular rate of 130 beats/min. The duration of the arrhythmia is uncertain and he is not anticoagulated. Echocardiography shows an LVEF of 30%. He is breathless at rest with raised jugular venous pressure, bibasal crackles and peripheral oedema, and still requires intravenous diuretic therapy. Blood pressure is 118/74 mmHg, oxygen saturation 96% on air, and there is no syncope, myocardial ischaemia, shock or life-threatening pulmonary oedema. Which is the most appropriate initial pharmacological treatment for ventricular rate control?

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Correct answer: B — Intravenous digoxin

Intravenous digoxin is the preferred initial rate-control agent. He is haemodynamically stable but has acutely decompensated HFrEF still requiring intravenous diuresis. Resuscitation Council UK tachyarrhythmia guidance advises that in stable AF with LVEF below 40% a beta-blocker or digoxin is considered, and digoxin is favoured when heart failure is decompensated because it lacks negative inotropy. Verapamil and diltiazem are explicitly excluded: NICE NG196 states calcium-channel blockers must not be used in AF with suspected acute decompensated heart failure, as negative inotropy worsens pulmonary oedema. Oral bisoprolol has slow onset and beta-blockade is generally deferred until intravenous diuretics are no longer needed. Amiodarone is reserved for haemodynamic instability with severe LV impairment and risks chemical cardioversion in AF of uncertain duration without anticoagulation. If life-threatening instability developed, synchronised cardioversion would supersede drug therapy.

Reference: Resuscitation Council UK. Adult advanced life support Guidelines (2025), tachyarrhythmia/atrial fibrillation section: https://www.resus.org.uk/professional-library/2025-resuscitation-guidelines/adult-advanced-life-support-guidelines (supported by NICE NG196, 2021: https://www.nice.org.uk/guidance/ng196/chapter/Recommendations)