Box 2Rate control summary

• Note that negative inotropes (beta-blockers and calcium channel-blockers) are contraindicated in patients with decompensated HFrEF with hypoperfusion, and beta-blockers should be dosed properly (start low, titrate slowly) in patients with compensated HFrEF (see Box 6)
• Goal is for HR < 110 at rest, and adequate symptom control.
• Use oral agents, preferentially, and titrate them often (e.g., every 6 hours) to goal. Oral metoprolol is the drug of choice in most patients (unless there is a contraindication). Oral diltiazem is an alternative. See Table 3 for additional drug and dosing information.
• If more rapid rate control is desired, use non-continuous (bolus) IV therapy with metoprolol or diltiazem. Continuous IV therapy should not be frequently required. See Table 3 for additional drug and dosing information.
• Patients admitted on a continuous drip for rate control should be converted to an oral agent ASAP.
• If heart rate is difficult to control with one agent, change to (or add) another. In some cases, second line rate control medications may be necessary (see Table 3). If heart rate and/or symptoms remain difficult to control after 48 hours, consider a rhythm-control strategy.