Treatment for Tachycardia and Heart Failure

Primary Pharmacological Strategy

The European Society of Cardiology recommends beta-blockers as the cornerstone therapy for patients with both tachycardia and heart failure, as they simultaneously address the tachycardia while improving heart failure outcomes through sympathetic nervous system suppression and heart rate reduction 1
Beta-blockers must be initiated in all patients with heart failure and tachycardia unless absolute contraindications exist, such as asthma, severe bronchial disease, symptomatic bradycardia, or decompensated heart failure requiring inotropic support 2
The American Heart Association recommends starting with extremely low doses of beta-blockers, such as metoprolol tartrate 12.5 mg twice daily, metoprolol succinate 12.5-25 mg daily, bisoprolol 1.25 mg daily, or carvedilol 3.125 mg twice daily, and doubling the dose every 1-2 weeks if tolerated, targeting maximum doses shown effective in trials 2

The European Heart Rhythm Association recommends rate control as mandatory for patients with atrial fibrillation and heart failure, with digoxin as the first choice for symptomatic patients, and beta-blockers, digoxin, or combination therapy for asymptomatic patients 3
The American College of Cardiology recommends considering electrical cardioversion for persistent atrial fibrillation, though rate control may be equally effective as rhythm control in heart failure patients 4
The Heart Rhythm Society recommends amiodarone as the preferred antiarrhythmic agent for symptomatic sustained ventricular tachycardia, and ICD therapy for life-threatening ventricular arrhythmias 4

The European Society of Cardiology recommends first increasing diuretics or ACE inhibitor dose, then temporarily reducing beta-blocker dose only if necessary, and always attempting reintroduction and uptitration when the patient stabilizes in cases of worsening heart failure during beta-blocker titration 2
The American Heart Association recommends reducing vasodilators first, then reducing beta-blocker dose only if hypotension persists, in cases of hypotension during titration 2

The European Heart Journal recommends not withholding beta-blockers due to age alone, as elderly patients benefit equally but require lower initial doses and slower titration 4
The American College of Cardiology recommends not abruptly discontinuing beta-blockers in patients with coronary artery disease, but rather tapering over 1-2 weeks to prevent severe exacerbation of angina, myocardial infarction, or ventricular arrhythmias 4
The Heart Failure Society of America recommends not using inotropic agents routinely, as they increase mortality and should be reserved for severe decompensation or as a bridge to transplantation, and using phosphodiesterase inhibitors rather than catecholamines if inotropic support is needed in a patient on beta-blockade 2