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Atrial Fibrillation - Rate Control — EECC MCQ

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ModerateArrhythmia & ElectrophysiologyAtrial Fibrillation - Rate ControlEECC

A 75-year-old woman with permanent atrial fibrillation and a resting ventricular rate of 110 bpm is seen in clinic. She has heart failure with LVEF 40% and is on bisoprolol 10 mg, ramipril 5 mg, and apixaban 5 mg twice daily. Her symptoms of breathlessness (NYHA II-III) may be partly rate-related. Which medication should be added to improve rate control?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Digoxin 125 micrograms once daily

Explanation lettering: E = shown as A · A = shown as B · B = shown as C · C = shown as D · D = shown as E

Per the 2024 ESC AF Guidelines, for rate control in AF with HF and reduced LVEF, beta-blockers and digoxin are the recommended agents. This patient is already on maximal bisoprolol, so adding digoxin is appropriate. Non-dihydropyridine CCBs (A, D) are contraindicated in HFrEF/HFmrEF. Flecainide (C) is contraindicated in structural heart disease. Ivabradine (E) is ineffective in AF. Apply this conclusion only to the clinical circumstances stated, with appropriate specialist review, contraindication checks, shared decision-making and follow-up. Reassess if the physiology, treatment response or competing risk changes. The competing options would require a different haemodynamic profile, diagnosis, procedural indication or risk balance from the one described here.

Reference: ESC (2024): Guidelines for the Management of Atrial Fibrillation: https://bnf.nice.org.uk/