D. Digoxin – Explanation

Digoxin is strongly indicated for coexistent atrial fibrillation and heart failure. Beta-blockers should
not be introduced until any heart failure has been stabilised. Giving amiodarone or flecainide may
result in cardioversion before the patient has been adequately anticoagulated
If there was a more acute history and the patient was in significant heart failure then DC
cardioversion would be appropriate, as per Advanced Life Support guidelines
Atrial fibrillation: rate control and maintenance of sinus rhythm
The Royal College of Physicians and NICE published guidelines on the management of atrial
fibrillation (AF) in 2006. The following is also based on the joint American Heart Association (AHA),
American College of Cardiology (ACC) and European Society of Cardiology (ESC) 2012 guidelines

Agents used to control rate in patients with atrial fibrillation

• beta-blockers
• calcium channel blockers
• digoxin (not considered first-line anymore as they are less effective at controlling the heart rate
  during exercise. However, they are the preferred choice if the patient has coexistent heart failure)

Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation

• sotalol
• amiodarone
• flecainide
• others (less commonly used in UK): disopyramide, dofetilide, procainamide, propafenone, quinidine
  The table below indicates some of the factors which may be considered when considering either a
  rate control or rhythm control strategy