A lesson I learned caring for a recent patient: CHF exacerbation in Afib with RVR
Clinical Question: What is the best way to rate control in decompensated heart failure?
Our first instinct when we see patients with A-fib with RVR is to reach for diltiazem or our beta blocker of choice, however, these are not the best choice in this subset of patients.
From the 2014 AHA/ACC Guidelines: “For rate control, intravenous nondihydropyridine calcium channel antagonists, intravenous beta blockers, and dronedarone should not be administered to patients with decompensated HF”. (Class III causing harm, level of evidence of C). While these drugs may slow the rate, they also exert anti-ionotropic effects that can reduce the patient’s already diminished cardiac output.
Instead, “in the absense of pre-excitation, intravenous digoxin or amiodarone is recommended to control heart rate acutely in patients with HF” (Class I, LoE B).
Digoxin – 0.25 mg IV w/ repeat dosing to a maximum of 1.5 mg over 24 hr
Amiodarone – 300 mg IV over 1 hr, then 10-50 mg/hr over 24 hr (this is different from the default order in Epic)
If in doubt you can always put the US on the patient’s heart – if the squeeze looks poor you are better off avoiding CCBs/BBs.
Full guidelines can be found here, CHF recs are in section 6.6 – http://content.onlinejacc.org/article.aspx?articleid=1854230
Anyone have any other tips or recommendations for caring for these challenging patients?