From the Guidelines
I strongly recommend initiating a diuretic, specifically furosemide 20-40mg daily, to address the patient's symptoms of shortness of breath and fluid retention, as these symptoms suggest volume overload, which is common in elderly patients with atrial fibrillation, especially when they have early signs of cardiac dysfunction as indicated by the low-normal ejection fraction. The patient's presentation with dyspnea and fluid retention, in the context of atrial fibrillation and an LVEF of 50-55%, suggests the need for immediate management of volume overload, which can be achieved with diuretics, as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. In addition to diuretic therapy, optimizing rate control is crucial, and since the patient is already on diltiazem, ensuring the dose is adequate (target heart rate <110 bpm at rest) is essential, with consideration of adding a beta-blocker if the patient can tolerate it, as suggested by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1. The patient should also be evaluated for anticoagulation therapy based on his CHA₂DS₂-VASc score, which is likely elevated given his age alone. For long-term management, reassessing his candidacy for rhythm control strategies such as catheter ablation, particularly if symptoms persist despite rate control and diuretic therapy, is important, as the combination of atrial fibrillation and fluid retention may indicate early heart failure with preserved ejection fraction (HFpEF), which is why addressing volume status is crucial while maintaining adequate rate control to prevent further cardiac remodeling and deterioration of ventricular function. Key considerations in managing this patient include:
- Diuretic therapy to manage volume overload
- Optimization of rate control with diltiazem and potential addition of a beta-blocker
- Evaluation for anticoagulation therapy
- Consideration of rhythm control strategies for long-term management
- Addressing the potential for early HFpEF and its implications on management.
From the Research
Management of Heart Failure
The patient in question has persistent atrial fibrillation, dyspnea, and fluid retention, with an LVEF of 50-55% and is currently on diltiazem. According to the studies, the next best step in managing this patient would involve:
- Using diuretics to relieve symptoms of fluid retention, as recommended by 2 and 3
- Considering the use of angiotensin-converting enzyme (ACE) inhibitors, beta blockers, or angiotensin II receptor blockers, as recommended by 2 and 4
- Avoiding or withdrawing nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and calcium channel blockers, as recommended by 2
Diuretic Therapy
The use of diuretics, particularly loop diuretics, is a crucial aspect of managing heart failure, as stated in 3 and 5. The studies suggest:
- Loop diuretics are the preferred diuretic for relieving congestion symptoms, with a class I recommendation by clinical guidelines 3
- Low-dose continuous infusion of furosemide can be effective in achieving diuresis and is not associated with a detectable effect on renal function, as shown in 5
- Diuretic resistance is a major challenge to decongestion therapy, but therapy options have emerged to help overcome this resistance, as discussed in 3
Treatment Strategies
The treatment strategies for heart failure with reduced ejection fraction (HFrEF) involve:
- Using diuretics to relieve symptoms, as recommended by 2 and 4
- Applying disease-modifying drug and device therapies, as discussed in 4
- Considering the use of β-blockers, angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers as foundational therapy, as recommended by 4
- Adding a mineralocorticoid receptor antagonist in patients with persistent symptoms, as recommended by 4