Antiarrhythmics in HFrEF — EECC MCQ
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Correct answer: C — IV amiodarone — the only antiarrhythmic drug not contraindicated in HFrEF; flecainide, propafenone, sotalol, and dronedarone are all contraindicated in HFrEF due to negative inotropic or proarrhythmic effects
In HFrEF, most antiarrhythmic drugs are contraindicated: (1) flecainide/propafenone (Class IC) — negative inotropy, proarrhythmic in structural heart disease (CAST trial); (2) sotalol — negative inotropy and QT prolongation; (3) dronedarone — increased mortality in HFrEF (ANDROMEDA trial) and permanent AF (PALLAS); (4) vernakalant — contraindicated in NYHA III-IV and LVEF <35%. Amiodarone is the only antiarrhythmic that can be used in HFrEF (Class III with I, II, and IV properties but minimal negative inotropy). The ESC 2024 AF Guidelines recommend IV amiodarone (300 mg over 20-60 min, then 900 mg/24h) for pharmacological cardioversion in HFrEF. If cardioversion fails or is not appropriate, electrical cardioversion under sedation is safe in all EF ranges.
Reference: ESC (2024): AF Guidelines