A 68-year-old man presents to the Emergency Department with palpitations and breathlessness that started 2 hours ago. He has no chest pain.
Past medical history:
- Hypertension
- Type 2 diabetes mellitus
Medications:
- Ramipril 10mg daily
- Metformin 1g twice daily
Examination:
- Appears comfortable at rest
- Heart rate 142 bpm irregularly irregular
- Blood pressure 138/82 mmHg
- Respiratory rate 18/min
- Oxygen saturation 96% on room air
Investigations:
- ECG shows atrial fibrillation with ventricular rate of 142 bpm
- No acute ischaemic changes
What is the MOST appropriate immediate management?
A
IV metoprolol 5mg over 5 minutes, repeat if necessary, and consider electrical cardioversion
B
Oral bisoprolol 2.5mg daily and arrange outpatient cardiology review within 2 weeks
C
IV amiodarone 300mg over 1 hour followed by 900mg over 24 hours
D
Immediate synchronised DC cardioversion under sedation without anticoagulation
E
Oral digoxin 500mcg loading dose and arrange admission for rate control