A 65-year-old man with HFrEF (LVEF 30%) on optimal GDMT has persistent NYHA class III symptoms. His ECG shows atrial fibrillation with a ventricular rate of 110 bpm. Which statement regarding rate control strategy is correct?
- A Lenient rate control (resting HR <110 bpm) is inferior to strict rate control (resting HR <80 bpm) in heart failure
- B Beta-blockers are first-line for rate control in HFrEF with atrial fibrillation, with a lenient target of resting HR <110 bpm being acceptable ✓
- C Digoxin is contraindicated in atrial fibrillation with heart failure
- D Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) are preferred over beta-blockers for rate control
Correct answer: B. Beta-blockers are first-line for rate control in HFrEF with atrial fibrillation, with a lenient target of resting HR <110 bpm being acceptable
Explanation
The RACE II trial demonstrated that lenient rate control (resting HR <110 bpm) is non-inferior to strict rate control in most patients, including those with heart failure. Beta-blockers remain first-line for rate control in HFrEF with AF because they provide both rate control and mortality benefit. Digoxin is used as add-on therapy, not contraindicated. Non-dihydropyridine calcium channel blockers are contraindicated in HFrEF due to negative inotropic effects.
Reference: Braunwald's Heart Disease, 12th ed.
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