If beta-blockers are contraindicated for rate control of AF with RVR in ACS, which option is recommended?

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Multiple Choice

If beta-blockers are contraindicated for rate control of AF with RVR in ACS, which option is recommended?

In ACS with AF with rapid ventricular response, the goal is to reduce heart rate to lower myocardial oxygen demand while avoiding worsening hemodynamics. If beta-blockers can’t be used, a nondihydropyridine calcium channel blocker — such as diltiazem or verapamil — is an appropriate choice because it slows AV nodal conduction, effectively decreasing the ventricular rate. The IV form provides rapid control, but it must be used with careful blood pressure monitoring since these drugs can lower BP and have negative inotropic effects, which can be risky if there’s LV dysfunction or hypotension. Lidocaine targets ventricular arrhythmias, not rate control in AF. Digoxin has a slower onset and is not ideal for acute rate control in the setting of RVR. Starting anticoagulation without addressing the fast rate leaves ongoing ischemia risk, and not attempting rate control is not appropriate for ACS. Thus, IV calcium channel blocker with blood pressure monitoring is the recommended approach.

In ACS with AF with rapid ventricular response, the goal is to reduce heart rate to lower myocardial oxygen demand while avoiding worsening hemodynamics. If beta-blockers can’t be used, a nondihydropyridine calcium channel blocker — such as diltiazem or verapamil — is an appropriate choice because it slows AV nodal conduction, effectively decreasing the ventricular rate. The IV form provides rapid control, but it must be used with careful blood pressure monitoring since these drugs can lower BP and have negative inotropic effects, which can be risky if there’s LV dysfunction or hypotension.

Lidocaine targets ventricular arrhythmias, not rate control in AF. Digoxin has a slower onset and is not ideal for acute rate control in the setting of RVR. Starting anticoagulation without addressing the fast rate leaves ongoing ischemia risk, and not attempting rate control is not appropriate for ACS. Thus, IV calcium channel blocker with blood pressure monitoring is the recommended approach.

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