AF Rate Control in HFrEF — RACP Adult Medicine MCQ

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EasyCardiologyAF Rate Control in HFrEFRACP Adult Medicine

A 60-year-old man with known HFrEF (LVEF 30%) on optimal therapy develops AF with rapid ventricular rate (HR 140 bpm). He is haemodynamically stable but symptomatic. What rate control agent is CONTRAINDICATED in HFrEF?

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Correct answer: B — Diltiazem

Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are CONTRAINDICATED in HFrEF due to their negative inotropic effects, which can worsen heart failure and cause haemodynamic collapse. Rate control in HFrEF with AF uses beta-blockers (if tolerated), digoxin, or amiodarone. For acute rate control in HFrEF, digoxin and/or amiodarone are often needed as beta-blockers may worsen acute decompensation. If haemodynamically unstable, synchronised DC cardioversion is appropriate.

Reference: eTG – 2025 – Cardiovascular; ESC – 2023 – Heart Failure Guidelines