A 38-year-old man is admitted with palpitations and an episode of pre-syncope

A 38-year-old man is admitted with palpitations and an episode of pre-syncope. He had completed a half-marathon for charity that afternoon and had since been drinking beer with friends to celebrate. He estimates that he has consumed some 6–8 pints of lager over the past 5 h. On examination his BP is 110/60 mmHg, with pulse 150/min. His chest is clear, with no signs of left ventricular failure (LVF). Investigations:

Hb 13.2 g/dl
WCC 8.1 x10 /l
PLT 200 x10 /l
Na 138 mmol/l
K 3.9 mmol/l
Creatinine 110 micromol/l
ECG Atrial flutter with 2:1 block
CXR No evidence of cardiomegaly or heart failure
Which of the following is the most appropriate intervention?
Explanation

Your answer was incorrect
IV flecainideA
IV digoxinB
IV verapamilC
IV amiodaroneD
IV esmololE

IV amiodaroneD Dr.Hisham Alshamekh
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IV amiodarone, would be the correct agent for pharmacological cardioversion in the presence of structural heart disease, and is indeed an alternative to flecainide even with a structurally normal heart.
This patient is fit and healthy, with no history of previous ischaemic heart disease or evidence of structural heart disease. As such, pharmacological cardioversion with flecainide is indicated and is associated with the greatest chance of attaining sinus rhythm.
IV digoxin, is less frequently used in clinical practice now. It provides rate control and is a weakly positive inotrope, although it may be associated with increased cardiovascular risk. This has niched its use to the elderly with symptoms despite other interventions. IV digoxin and verapamil achieve rate control rather than attaining sinus rhythm.
IV verapamil, is used for urgent rate control in acute atrial fibrillation (AF) as an alternative to b-blockade. It can also be administered alongside an agent for rhythm control, such as flecainide. A contraindication to its use as monotherapy in this situation is the high likelihood of successful cardioversion
Esmolol, is a short-acting beta-blocker used in the treatment of paroxysmal supraventricular tachycardia (SVT) such as AF or atrial flutter. Its use is not routinely recommended in this situation where cardioversion may be possible.