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Amiodarone for Rate Control — EECC MCQ

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ModerateArrhythmia & ElectrophysiologyAmiodarone for Rate ControlEECC

A 72-year-old man with permanent AF and HFrEF (LVEF 30%) presents with a ventricular rate of 140 bpm despite bisoprolol 10 mg and digoxin 125 microg. Amiodarone is considered for rate control as a last resort. What is the evidence for amiodarone in AF rate control?

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Correct answer: B — Amiodarone is effective for rate control but is generally reserved as a last-line agent due to its significant extracardiac toxicity profile; it is the only antiarrhythmic drug not contraindicated in HFrEF

Amiodarone has multiple electrophysiological effects including AV nodal slowing (class III, I, II, and IV actions), making it effective for rate control. Crucially, it is the only antiarrhythmic that is not contraindicated in HFrEF (unlike flecainide, sotalol, and dronedarone). However, its extensive toxicity profile (thyroid dysfunction in 15-20%, pulmonary fibrosis, hepatotoxicity, photosensitivity, corneal deposits, peripheral neuropathy) limits its use to situations where other rate control agents have failed. The 2024 ESC AF Guidelines position amiodarone as a last-line rate control option (Class IIb) when beta-blockers, digoxin, and AV node ablation with CRT are not feasible or have failed. Regular monitoring (TFTs 6-monthly, LFTs, PFTs, ophthalmology) is mandatory.

Reference: ESC (2024): AF Guidelines