What is the optimal management plan for a 72-year-old male with HFrEF, A-fib on Xarelto (rivaroxaban), CAD, untreated OSA, MR, and a history of AAA repair, presenting with increased shortness of breath and weight gain after a brief interruption of Xarelto?

Optimal Management Plan for HFrEF with Atrial Fibrillation and Recent Decompensation

Immediate Priority: Resume Anticoagulation and Optimize GDMT

The most critical immediate action is to ensure strict adherence to Xarelto (rivaroxaban) for stroke prevention, as this patient's CHA2DS2-VASc score is extremely high (≥6 points: HF, age >75, vascular disease), and the medication interruption likely contributed to his acute decompensation. 1

Anticoagulation Management

• Continue Xarelto 20 mg once daily for stroke prevention in atrial fibrillation, regardless of whether rhythm control is achieved, as the thromboembolic risk remains elevated even if sinus rhythm is restored 1
• Address medication adherence barriers immediately—the insurance lapse that caused Xarelto interruption must not recur, as this patient demonstrated acute decompensation with 20-pound weight gain and bilateral pleural effusions during the anticoagulation gap 2
• Do not reduce the Xarelto dose unless creatinine clearance falls below 50 mL/min; this patient appears to have adequate renal function based on the clinical scenario 2

Heart Failure Guideline-Directed Medical Therapy (GDMT)

Your current GDMT initiation is appropriate but incomplete due to hypotension preventing ACE/ARB/ARNI therapy. The priority sequence should be:

Currently Initiated (Appropriate):

• Metoprolol succinate 150 mg daily is the correct beta-blocker choice for HFrEF (one of the three mortality-reducing beta-blockers: bisoprolol, carvedilol, or metoprolol succinate) 1
• Spironolactone 25 mg daily is appropriate as a mineralocorticoid receptor antagonist for HFrEF 1, 3
• Farxiga (dapagliflozin) 10 mg daily is guideline-recommended SGLT2 inhibitor therapy for HFrEF 1

Critical Missing Component:

• Aggressively work to initiate ACE inhibitor, ARB, or ARNI as soon as blood pressure tolerates, as this is a Class I recommendation for all HFrEF patients unless contraindicated 1
• Consider starting with very low doses (e.g., lisinopril 2.5 mg daily or sacubitril/valsartan 24/26 mg twice daily) and uptitrating gradually while monitoring blood pressure and renal function 1
• If hypotension persists, optimize volume status with diuretics first (he already ran out of Bumex once—ensure consistent furosemide/bumetanide dosing), then retry RAAS inhibition 1

Atrial Fibrillation Rate and Rhythm Control Strategy

Your amiodarone initiation for rhythm control is reasonable given the new-onset severe cardiomyopathy (LVEF 25-30%), as this may represent tachycardia-induced cardiomyopathy. 1, 4

Current Rate Control Assessment:

• The 9/10/2025 heart rate of 86 bpm represents adequate lenient rate control (target <110 bpm resting), which is an acceptable initial approach 1, 4
• However, assess exercise heart rate control since he is a farmer actively baling hay—if he becomes symptomatic with activity, stricter rate control may be needed 1, 4

Rhythm Control Strategy:

• Continue amiodarone 200 mg daily as you have initiated, since this is the most effective antiarrhythmic with the lowest proarrhythmic risk in HFrEF patients 1
• Amiodarone provides dual benefit: rhythm control AND rate control if AF persists 1
• Consider electrical cardioversion after 3-4 weeks of amiodarone loading if he remains in persistent AF, as restoration of sinus rhythm may improve his LVEF if this is tachycardia-induced cardiomyopathy 1, 4
• The left heart catheterization showing no significant CAD supports that his reduced LVEF may be tachycardia-mediated or AF-related rather than ischemic 1, 4

If Rhythm Control Fails:

• Beta-blockers remain the preferred rate-control agent in HFrEF due to mortality benefit—you are already using metoprolol succinate appropriately 1, 4
• Digoxin can be added to metoprolol for additional rate control if needed, particularly effective for resting heart rate control in HFrEF 1, 4
• AV node ablation with cardiac resynchronization therapy (CRT) should be considered if pharmacologic rate control fails and he remains severely symptomatic, but only after attempting medical therapy 1

Critical Medication Adherence Intervention

This patient's medication non-adherence (running out of Bumex for a week, previous Xarelto gap) is a major threat to his survival. 4

• Implement a structured medication adherence program immediately
• Consider pill organizers, pharmacy auto-refill programs, or home health nursing visits
• Ensure he has a 90-day supply of all medications with automatic refills
• The insurance change that caused Xarelto interruption must be resolved with prior authorizations completed for all medications

LifeVest Management and ICD Consideration

• Continue LifeVest for now as appropriate for new-onset severe cardiomyopathy (LVEF 25-30%) 1
• Reassess LVEF in 3 months after optimizing GDMT and achieving rate/rhythm control—if LVEF remains ≤35% despite optimal medical therapy, he will meet criteria for primary prevention ICD 1
• Many patients with tachycardia-induced cardiomyopathy show significant LVEF improvement with rate/rhythm control and GDMT optimization 1, 4

Untreated Obstructive Sleep Apnea

The untreated OSA is a significant modifiable risk factor contributing to both his HFrEF and atrial fibrillation. 1

• Refer for sleep study and CPAP initiation urgently—OSA treatment can improve AF burden and HF outcomes 1
• OSA is independently associated with AF recurrence and HF progression 1

Follow-Up Plan

• Recheck in 2-4 weeks (as you planned) to assess:
  • Heart rate control at rest and with activity
  • Volume status and diuretic adequacy
  • Blood pressure tolerance for RAAS inhibitor initiation
  • Medication adherence verification
  • Rhythm status (still in AF vs. converted to sinus rhythm)
• Repeat echocardiogram in 3 months to reassess LVEF after GDMT optimization and rate/rhythm control 1
• Monitor for amiodarone toxicity: baseline and periodic thyroid function, liver function, pulmonary function tests, and ophthalmology evaluation 1

Key Pitfalls to Avoid

• Do not discontinue anticoagulation even if sinus rhythm is restored—his stroke risk remains high (CHA2DS2-VASc ≥6) 1
• Do not use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) for rate control in this patient with HFrEF (LVEF 25-30%) due to negative inotropic effects 1
• Do not perform AV node ablation without first attempting pharmacologic rate control 1
• Do not delay ACE/ARB/ARNI indefinitely—work aggressively on volume optimization to allow blood pressure tolerance for RAAS inhibition, as this is critical for HFrEF mortality reduction 1