Acute Pulmonary Oedema MS with AF — EECC MCQ

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ModerateValvular Heart DiseaseAcute Pulmonary Oedema MS with AFEECC

A 45-year-old woman with known severe mitral stenosis (MVA 0.7 cm²) and AF develops acute pulmonary oedema. She is haemodynamically unstable (SBP 80 mmHg). What is the emergency management?

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Correct answer: B — Urgent cardioversion to restore sinus rhythm (AF with rapid rate is the typical precipitant of decompensation in MS) plus IV diuretics for pulmonary oedema; if haemodynamics do not improve, emergency PMBC or surgical MVR may be needed

Acute pulmonary oedema in severe MS with new AF is a medical emergency. The mechanism: loss of atrial contraction (AF) combined with tachycardia (shortened diastolic filling time across the stenotic MV) causes a dramatic rise in LA pressure → acute pulmonary oedema. Management: (1) URGENT cardioversion (most effective intervention — restoring sinus rhythm immediately improves haemodynamics by: restoring atrial kick AND slowing HR to lengthen diastolic filling time); (2) IV diuretics (furosemide) for acute pulmonary congestion; (3) supplemental oxygen/NIV for respiratory support; (4) rate control (if cardioversion delayed or AF recurs): IV beta-blocker or digoxin — NOT verapamil/diltiazem which may worsen hypotension; (5) anticoagulation for AF in MS (warfarin — Class I); (6) definitive treatment: PMBC (if anatomy favourable) or surgical MVR. The 2025 ESC VHD Guidelines emphasise that AF in severe MS often requires urgent intervention.

Reference: ESC/EACTS (2025): VHD Guidelines