A 60-year-old man with ischemic cardiomyopathy (LVEF 30%) and NYHA class II heart failure presents with new-onset atrial fibrillation of 6 hours duration. He is hemodynamically stable. Which antiarrythmic drug is safest for pharmacological cardioversion in this patient?
- A Flecainide 300 mg single oral dose
- B Amiodarone 150 mg IV over 10 minutes, then 1 mg/min infusion ✓
- C Propafenone 600 mg single oral dose
- D Sotalol 120 mg IV over 5 minutes
Correct answer: B. Amiodarone 150 mg IV over 10 minutes, then 1 mg/min infusion
Explanation
Flecainide and propafenone (class IC) are contraindicated in structural heart disease and heart failure due to increased proarrhythmic risk (CAST trial). Sotalol is class III but carries QT prolongation risk and negative inotropy. Amiodarone is the safest class III agent for pharmacological cardioversion in patients with structural heart disease and reduced ejection fraction, as it has minimal negative inotropic effect.
Reference: 2020 ESC Guidelines for Atrial Fibrillation
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Written and medically reviewed by the StethoPrep medical team.