Atrial Fibrillation with RVR MCQ — NEET PG Practice Question | NEETPGAI
Atrial Fibrillation with RVR
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stethoscope Medicine
A 68-year-old man with hypertension, type 2 diabetes, and a remote stroke 4 years ago presents with palpitations and lightheadedness for 12 hours. On examination, his heart rate is irregularly irregular at 142 bpm, BP 132/84 mmHg, and SpO2 96% on room air. He is alert and hemodynamically stable. ECG shows the pattern marked **A** in the diagram — absent P waves, irregularly irregular R-R intervals, and fibrillatory waves at the baseline. What is the most appropriate IMMEDIATE pharmacologic management for rate control in this hemodynamically stable patient?
A. Intravenous metoprolol or diltiazem to achieve target heart rate <110 bpm at rest
B. Oral flecainide for pharmacologic cardioversion without prior anticoagulation
C. Intravenous digoxin as first-line agent for rapid rate control
D. Intravenous amiodarone for combined rate and rhythm control
Explanation
Why intravenous metoprolol or diltiazem is correct
The pattern marked A — irregularly irregular tachycardia with absent P waves and fibrillatory baseline — is atrial fibrillation with rapid ventricular response (AF with RVR). In a hemodynamically STABLE patient, the AHA/ACC 2023 AF Guidelines mandate pharmacologic rate control as first-line therapy. Intravenous beta-blockers (metoprolol 5 mg IV q5min × 3 doses) or non-dihydropyridine calcium channel blockers (diltiazem 0.25 mg/kg IV bolus then infusion 5–15 mg/h) are the preferred agents. The target is <110 bpm at rest (lenient strategy per RACE II trial), or <80 bpm if symptomatic. This patient's stable hemodynamics, normal troponin, and normal EF support this approach.
Why each distractor is wrong
Intravenous digoxin as first-line agent: Digoxin is reserved for patients with concurrent HFrEF or when beta-blockers and CCBs are contraindicated. It is less effective in active sympathetic states and is NOT first-line for AF with RVR in this clinical context.
Intravenous amiodarone for combined rate and rhythm control: Amiodarone is reserved for critically ill patients or those with HFrEF and provides both rate and rhythm control, but it is NOT first-line for chronic AF management due to organ toxicity (hepatic, pulmonary, thyroid, cardiac). This patient is stable and does not require amiodarone.
Oral flecainide for pharmacologic cardioversion: Flecainide is a Class IC antiarrhythmic suitable for rhythm control in structurally normal hearts, but it is NOT appropriate for acute rate control in AF with RVR. Additionally, cardioversion beyond 48 hours of AF onset requires either TEE-guided approach or 3 weeks of anticoagulation pre-cardioversion; this patient has no documented anticoagulation yet.
High-YieldNEET PG
In hemodynamically stable AF with RVR, IV beta-blockers or non-dihydropyridine CCBs are first-line; target HR <110 bpm at rest (RACE II). Digoxin and amiodarone are reserved agents.
AHA/ACC Atrial Fibrillation Guidelines 2023; RACE II trial on lenient vs. strict rate control
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