Atrial Fibrillation (rate control) — EECC MCQ
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Correct answer: A — IV diltiazem
This is haemodynamically stable atrial fibrillation with rapid ventricular response: BP is preserved, there is no heart failure and there is no pre-excitation/WPW. The immediate aim is ventricular rate control with an AV-nodal blocking drug. A rate-limiting calcium-channel blocker is appropriate in this setting; among the options, IV diltiazem provides rapid rate control and is the best initial choice. Immediate DC cardioversion is reserved for life-threatening haemodynamic instability or a selected rhythm-control strategy. IV amiodarone is not first-line rate control here and is generally reserved for rhythm control or situations such as LV impairment/heart failure where other agents may be unsuitable. Adenosine is for AV node-dependent SVT/diagnosis of regular narrow-complex tachycardia, not AF rate control. Digoxin has a slower onset and is not first-line for acute rapid rate control unless other rate-limiting options are unsuitable or the patient is sedentary with non-paroxysmal AF.
Reference: NICE guideline NG196: Atrial fibrillation: diagnosis and management (2021, current recommendations on rate control and acute presentation). https://www.nice.org.uk/guidance/ng196/chapter/recommendations