A 68-year-old woman with persistent AF and a ventricular rate of 52 bpm is started on rate control therapy. Despite maximal beta-blocker and digoxin therapy, her Holter shows a mean ventricular rate of 110 bpm with periods of rapid rate. Echocardiogram shows normal LVEF. What is the next recommended intervention?
- A Add amiodarone for rhythm control
- B Switch to calcium channel blocker
- C AV node ablation with permanent pacing (pace and ablate strategy) ✓
- D Perform pulmonary vein isolation immediately
Correct answer: C. AV node ablation with permanent pacing (pace and ablate strategy)
Explanation
When rate control fails despite multiple AV nodal blocking agents (tachy-brady or inadequate rate control), AV node ablation with permanent pacemaker implantation is the recommended strategy. This achieves complete rate control without the proarrhythmic and toxic effects of high-dose antiarrhythmics. Pulmonary vein isolation may still be considered but does not guarantee rate control.
Reference: 2020 ESC Guidelines for Atrial Fibrillation
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.