Question 23#

A 40-year-old man presents to A&E with a 12-hour history of sudden-onset palpitations. He has no previous medical history of note and the clinical examination is unremarkable. His troponin is negative. His ECG shows atrial fibrillation with a ventricular rate of 130 bpm, his BP is 110/70 mmHg, and his oxygen saturation is 98%. He has no symptoms associated with his palpitations.
What is the best management?

A) Amiodarone 300 mg IV loading followed by 900 mg over 24 hours
B) Flecainide 2 mg/kg over 0 minutes followed by oral dose
C) Digoxin 500 micrograms IV followed by 500 micrograms after 6 hours
D) Anticoagulate, rate control, and perform DC cardioversion in 6 weeks
E) Aspirin, atenolol 50 mg od, and review in clinic in 6 weeks

Correct Answer is B


The option of anticoagulation, rate control, and DC cardioversion is reasonable if the onset of atrial fibrillation is >48 hours or if unsure of duration. DC cardioversion could be performed immediately as the onset of AF appears to be acute, but there are no signs of haemodynamic compromise and therefore it does not need to be performed as an emergency. Beta-blockers are good for rate control but are less likely to cardiovert a patient to sinus rhythm than other options. Amiodarone is probably the first-choice drug for chemical cardioversion of patients with structural heart disease or heart failure. Digoxin is unlikely to cardiovert a patient to sinus rhythm and may even be profibrillatory. Flecainide is likely to cardiovert this patient faster than any of the other options, and is likely to be safe in a young patient with no evidence of cardiac disease.