Management of Heart Failure with Reduced Ejection Fraction and Atrial Fibrillation

Immediate Acute Management

The American College of Cardiology recommends immediate hospitalization for acute decompensated heart failure with aggressive diuretic therapy, initiation of guideline-directed medical therapy for heart failure with reduced ejection fraction, rate control for atrial fibrillation using beta-blockers, and anticoagulation for stroke prevention 1, 2, 3
Initiate intravenous loop diuretics immediately to relieve pulmonary congestion and reduce extracellular fluid volume excess, with monitoring of urine output, vital signs, body weight, and clinical signs of congestion 1
The initial intravenous dose should equal or exceed any chronic oral daily dose if the patient were previously on diuretics 1
Monitor daily serum electrolytes, urea nitrogen, and creatinine concentrations during IV diuretic use 1
If diuresis is inadequate, intensify the regimen by using higher doses of loop diuretics, adding a second diuretic, or using continuous infusion of loop diuretics 1

The American Heart Association recommends initiating beta-blocker therapy as the first-line agent for rate control in patients with reduced ejection fraction 2, 3, 4
Beta-blockers are mandatory in heart failure with reduced ejection fraction as they improve morbidity and mortality 2, 5
Avoid non-dihydropyridine calcium channel blockers entirely as they are Class III (harm) in heart failure with reduced ejection fraction, increasing risk of heart failure worsening and hospitalization 2, 6
Target lenient rate control with resting heart rate <110 bpm initially, with stricter control (<80 bpm) if symptoms persist 3, 4
If beta-blocker monotherapy fails to achieve adequate rate control, add digoxin for combination therapy 2, 3, 4

The European Society of Cardiology recommends initiating four classes of medications that each independently reduce mortality by at least 20%: ACE inhibitor or ARB, beta-blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor 2, 3, 5
Initiate ACE inhibitor or ARB therapy in stable patients prior to hospital discharge, with uptitration to target doses 1, 2
Initiate beta-blocker therapy after optimization of volume status and successful discontinuation of IV diuretics, vasodilators, and inotropic agents, with uptitration to target doses 1, 2
Mineralocorticoid receptor antagonist should be included if heart failure with reduced ejection fraction is present, with monitoring of serum potassium 2

The American College of Cardiology recommends careful monitoring for bradycardia in patients with bifascicular block on beta-blocker therapy 1
Consider pacemaker evaluation if symptomatic bradycardia develops or if AV node ablation becomes necessary for refractory rate control 3

Provide written discharge instructions emphasizing diet, discharge medications, activity level, follow-up appointments, daily weight monitoring, and what to do if heart failure symptoms worsen 1
Arrange follow-up within 7-14 days of discharge to assess medication tolerance and clinical status, with evaluation at 6 months after presentation and at least annually or based on clinical need 1, 3
Continue uptitration of guideline-directed medical therapy to target doses in the outpatient setting 1, 5