How do I manage a 78-year-old female with congestive heart failure (CHF) with reduced ejection fraction (EF) of 25%, presenting with shortness of breath (SOB) on exertion, known history of atrial fibrillation (A Fib) on bisoprolol (beta-blocker) and perindopril (angiotensin-converting enzyme inhibitor (ACE inhibitor)), with tachycardia and hypotension?

Management of Elderly Patient with HFrEF, Atrial Fibrillation, and Acute Decompensation

For this 78-year-old female with HFrEF (EF 25%), atrial fibrillation, and acute decompensation presenting with SOB on exertion and tachycardia (HR 136) with borderline hypotension (BP 101/65), intravenous digoxin or amiodarone should be administered immediately to control heart rate while maintaining hemodynamic stability.

Initial Assessment and Management

• This patient presents with acute decompensation of heart failure with rapid atrial fibrillation, requiring urgent rate control while maintaining blood pressure 1
• The current medications (bisoprolol and perindopril) are appropriate for HFrEF with atrial fibrillation but require optimization 2
• The patient's borderline hypotension (101/65 mmHg) limits the use of additional beta-blockers or increased ACE inhibitor dosing in the acute setting 1

Immediate Management (First 1-2 hours)

• Administer intravenous digoxin or amiodarone to control heart rate acutely in the setting of HFrEF with hypotension 1
• Avoid additional beta-blocker doses or non-dihydropyridine calcium channel blockers due to the patient's hypotension and reduced EF 1
• Consider supplemental oxygen if hypoxemic and assess volume status to determine need for diuresis 1

Rate Control Strategy

• Target heart rate should be <100 bpm initially, with a goal of 60-100 bpm at rest and <110 bpm with mild exertion 1

• For acute rate control with hypotension and HFrEF:

  • IV digoxin is preferred as first-line therapy due to minimal effect on blood pressure 1
  • IV amiodarone can be used if digoxin is insufficient or contraindicated 1
  • Avoid additional beta-blocker doses until hemodynamically stable 1

• Once stabilized, optimize oral medications:

  • Continue bisoprolol but do not increase dose until blood pressure improves 1
  • Consider adding digoxin for chronic rate control 1

Optimization of HFrEF Therapy

After achieving rate control and hemodynamic stability:

• Maintain the patient on low-dose ACE inhibitor (perindopril) due to low blood pressure 1, 2
• Add a mineralocorticoid receptor antagonist (MRA) as it has minimal effect on blood pressure but significant benefits in HFrEF 1, 3
• Consider adding an SGLT2 inhibitor when hemodynamically stable, as it has minimal effect on blood pressure 1, 4
• Adjust diuretics based on volume status 1

Long-term Management Plan

• Once stabilized with heart rate <100 bpm and improved symptoms:
  • Gradually up-titrate bisoprolol if blood pressure allows 1, 2
  • Maintain perindopril at tolerated dose 2
  • Consider switching to sacubitril/valsartan if blood pressure improves above 100/60 mmHg 1, 2
  • Ensure appropriate anticoagulation for atrial fibrillation 1

Monitoring and Follow-up

• Monitor heart rate, blood pressure, renal function, and electrolytes closely during medication adjustments 1, 2
• Assess volume status daily and adjust diuretics accordingly 1
• Consider cardiology consultation for potential rhythm control strategy if rate control is difficult to achieve 1
• If rate control cannot be achieved with medications, consider AV node ablation with permanent pacing as a last resort 1

Common Pitfalls to Avoid

• Avoid aggressive up-titration of beta-blockers or ACE inhibitors in the setting of hypotension 1
• Do not use non-dihydropyridine calcium channel blockers (verapamil, diltiazem) in HFrEF patients due to negative inotropic effects 1, 5
• Avoid excessive diuresis which may worsen hypotension 1
• Do not attempt electrical cardioversion without prior adequate anticoagulation unless hemodynamically unstable 1

Special Considerations for Elderly Patients

• Start medications at lower doses and titrate more gradually 1, 2
• Monitor for orthostatic hypotension and fall risk 1
• Assess for polypharmacy and potential drug interactions 1
• Consider frailty and comorbidities when determining treatment intensity 1