Box 6Management of AF in patients with cardiac comorbidities

• Cardiology should be consulted to assist in the management of patients with HFrEF or other complex heart disease, urgently if needed.
• Patients with decompensated HFrEF (e.g., volume overload, pulmonary edema) but without signs of systemic hypoperfusion (see next bullet) should usually continue their home beta-blocker, but may not tolerate significant dose titration of that medication (or initiation of other negative inotropes) until they are again compensated.
• Patients with decompensated HFrEF with signs of systemic hypoperfusion (AKI, ALI, elevated lactate, poor response to diuretics, cool extremities, hypotension) should not be treated with negative inotropes (beta blockers or calcium channel blockers), even if they are tachycardic. Home beta-blockers should be held.
• Alternative approaches for immediately addressing RVR include:
  • ○ For unstable patients, see figure 1
  • ○ Tolerate the tachycardia while treating the underlying CHF (e.g., diuresis) - most appropriate for patients without severe tachycardia (ie, HR up to 130 BPM)
  • ○ Digoxin load (see Table 3) - 1^st line rate control agent for patients with decompensated heart failure
• Patients taking antiarrhythmic drugs for AF/AFL may benefit from early consultation with EP