Sun31October0735PM 3

A 52-year-old man is admitted in the early hours of the morning after suffering palpitations and presyncope. He is usually well and still plays veterans rugby. He had been at a party the previous evening during which he consumed seven pints of beer. He smokes 5 cigars per week.

Examination reveals a BP of 105/72 mmHg, pulse of 130 and atrial fibrillation. His chest is clear.

Investigations reveal:

Hb 138 g/L (135-180)

WCC 7.8 ×109/L (4-10)

PLT 302 ×109/L (130-400)

Na 136 mmol/L (135-145)

K 3.7 mmol/L (3.5-5.5)

Cr 112 µmol/L (70-120)

Troponin <0.05 -

ECG shows atrial fibrillation, no other acute changes.

CXR shows normal heart size, no evidence of heart failure.

Which of the following is the most appropriate intervention?

(Please select 1 option)

DC cardioversion This is the correct answer

IV amiodarone Incorrect answer selected

Oral sotalol

IV adenosine

IV flecainide

Explanation

Given this person has had no oral intake over the past few hours, and is young without a previous cardiac history, DC cardioversion is the most appropriate next step, as the chances of achieving permanent sinus rhythm are high. Binge drinking is well known as a potential trigger for paroxysmal AF. He should of course be given advice to moderate his alcohol consumption in future.

IV flecainide is associated with higher rates of conversion to sinus rhythm than amiodarone, and is the preferred choice for chemical cardioversion in patients with a structurally normal heart who have no previous history of IHD. Where there is some debate about duration of AF (that is, potentially >24 hours), anticoagulation is instituted prior to cardioversion because of the risk of precipitating emboli after sinus rhythm is attained. In this situation we can't exclude structural or ischaemic heart disease, and therefore DC cardioversion is preferred to flecainide.

Over the longer term, bisoprolol is indicated by NICE guidance as the first line prophylaxis against further episodes of paroxysmal AF. Adenosine has a role in terminating AV nodal re-entrant tachycardias and may be useful as a diagnostic aid in other paroxysmal SVTs.

Reference:

NICE. Atrial fibrillation: the management of atrial fibrillation (CG180).

Answer Statistics

1

26%

2

13%

3

18%

4

3%

5

42%

Times answered: 295