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AF Rate Control in COPD — EECC MCQ

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ModerateArrhythmia & ElectrophysiologyAF Rate Control in COPDEECC

A 62-year-old man with severe COPD (FEV1 32%) develops AF. He requires rate control. Beta-blockers are poorly tolerated (worsening bronchospasm). What rate control agent is appropriate?

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Correct answer: B — Non-dihydropyridine calcium channel blocker (diltiazem or verapamil) — provides effective AV nodal slowing without bronchospasm; or digoxin if CCBs are also contraindicated (e.g. in HFrEF)

AF rate control in patients with significant airways disease is challenging. Beta-blockers (even beta-1 selective) may worsen bronchospasm in severe COPD/asthma, particularly at higher doses. The 2024 ESC AF Guidelines recommend: (1) Non-DHP CCBs (diltiazem, verapamil) — effective rate control without bronchospasm, but contraindicated in HFrEF (LVEF <40%); (2) Digoxin — adequate at rest but poor during exercise (no adrenergic effect), no bronchospasm, safe in HFrEF; (3) If beta-blocker is needed: very low-dose bisoprolol (1.25 mg) with careful titration and lung function monitoring. Sotalol has beta-blocking properties and is not suitable. Amiodarone (last resort for rate control) can rarely cause pulmonary toxicity, which is particularly problematic in patients with already compromised lung function.

Reference: ESC (2024): AF Guidelines; NICE COPD Guidelines