From the Guidelines
The treatment for tachycardia in decompensated heart failure should focus on optimizing heart failure therapy and cautiously using beta-blockers or alternative rate control agents, such as amiodarone, to manage the rapid heart rate, as recommended by the 2014 AHA/ACC/HRS guideline 1.
Key Considerations
- Initial management includes optimizing heart failure therapy with intravenous diuretics like furosemide to reduce fluid overload, and oxygen supplementation to improve oxygenation.
- For rate control, beta-blockers such as metoprolol or esmolol are used cautiously as they can worsen heart failure acutely, as noted in the 2008 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1.
- In patients who cannot tolerate beta-blockers, diltiazem or amiodarone may be considered, with amiodarone being particularly useful in critically ill patients.
- The underlying cause of tachycardia must be identified and treated, which may include addressing electrolyte abnormalities, infection, or ischemia.
Rate Control Strategies
- Beta-blockers are the most common agents used for rate control, followed by nondihydropyridine calcium channel blockers, digoxin, and amiodarone, as discussed in the 2014 AHA/ACC/HRS guideline 1.
- Electrical cardioversion is preferred in patients with decompensated HF, ongoing myocardial ischemia, or hypotension, although this may carry an increased thromboembolic risk, as mentioned in the 2014 AHA/ACC/HRS guideline 1.
Important Safety Considerations
- Nondihydropyridine calcium channel antagonists should not be used in patients with decompensated HF as these may lead to further hemodynamic compromise, as warned in the 2014 AHA/ACC/HRS guideline 1.
- Dronedarone should not be used to control the ventricular rate in patients with permanent AF as it increases the risk of the combined endpoint of stroke, MI, systemic embolism, or cardiovascular death, as noted in the 2014 AHA/ACC/HRS guideline 1.
From the FDA Drug Label
4 CONTRAINDICATIONS Esmolol hydrochloride is contraindicated in patients with: ... Decompensated heart failure: May worsen heart failure.
The FDA drug label does not answer the question.
From the Research
Treatment of Tachycardia in Decompensated Heart Failure
- The treatment of tachycardia in decompensated heart failure involves the use of beta-blockers, which are recommended as the standard of care for patients with chronic heart failure due to systolic dysfunction 2.
- Beta-blockers should be continued for patients hospitalized with acute decompensated heart failure due to left ventricular systolic dysfunction, in the absence of contraindications 2.
- However, in patients with severe acute heart failure, including those with resolved cardiogenic shock, beta-blocker initiation can be hazardous, and there are limited data on the management of beta-blockers in these situations 3.
- The doses of beta-blockers used in clinical practice are often substantially less than the doses achieved in randomized clinical trials and recommended in national guidelines 4.
- A practical algorithm for the prescription and monitoring of beta-blocker therapy in critical settings, such as severe decompensated acute heart failure, has been proposed by experts 3.
- The initial effects of beta-blocker therapy may be neutral or adverse, but benefits accumulate gradually over a period of weeks to months, and patience, perseverance, and education are required to allow patients to reap the full benefits of beta-blocker therapy 5.
- Beta-blocker therapy should be initiated at a low dose and slowly titrated upward as tolerated, with a patient's heart failure being stable for at least 2 weeks before the dose is adjusted upward 6.