Which of the following agents should be avoided in patients with heart failure due to their negative inotropic effects?

In patients with heart failure, it is important to avoid agents that can have negative inotropic effects, as these can worsen cardiac function. Sotalol is a class III antiarrhythmic that not only has the potential to inhibit adrenergic activity but can also decrease cardiac contractility. This negative inotropic effect is particularly concerning in patients with heart failure, where maintaining adequate cardiac output is crucial.

In contrast, amiodarone is typically used more cautiously in heart failure patients due to its overall favorable profile and less pronounced negative inotropic effects compared to sotalol. Flecainide, while also an antiarrhythmic, is generally avoided in heart failure due to its negative inotropic properties, but the focus here is on the agent that is most clearly contraindicated when compared to others commonly used in heart failure management. Digoxin, on the other hand, is often utilized in heart failure as it exhibits positive inotropic effects, enhancing cardiac contractility. Thus, sotalol stands out as the agent that should be avoided in this patient population due to its negative inotropic impact.