How to manage a patient with atrial fibrillation (AF) and tachycardia, on bisoprolol (Beta blocker) 10mg, with a history of right heart failure, during a hemodialysis session?

From the Guidelines

For a patient on hemodialysis with fast atrial fibrillation (heart rate 150), stable blood pressure, already on bisoprolol 10 mg, and known right heart failure, I recommend continuing the hemodialysis session with close monitoring while initiating additional rate control measures, prioritizing beta-blockers and/or digoxin as first-line therapy for rate control in patients with AF and LVEF ≤40% as per the 2024 ESC guidelines 1. Given the patient's existing beta-blocker therapy, consider administering intravenous diltiazem (starting at 0.25 mg/kg over 2 minutes) for immediate rate control, as beta-blockers and diltiazem are recommended for heart rate control in patients with AF and LVEF >40% or ≤40% 1. Key considerations in managing this patient include:

• Monitoring for hemodynamic changes during the dialysis session, as ultrafiltration may exacerbate right heart failure.
• Avoiding digoxin due to its variable clearance in dialysis patients, although it is recommended for rate control in patients with AF and LVEF ≤40% 1.
• Obtaining an ECG after dialysis to assess rhythm and considering anticoagulation based on CHA₂DS₂-VASc score.
• Arranging echocardiography to evaluate right ventricular function and potential valvular issues. This approach is guided by the most recent and highest quality evidence from the 2024 ESC guidelines for the management of atrial fibrillation 1, prioritizing morbidity, mortality, and quality of life outcomes.

From the FDA Drug Label

WARNINGS Cardiac Failure Sympathetic stimulation is a vital component supporting circulatory function in the setting of congestive heart failure, and beta-blockade may result in further depression of myocardial contractility and precipitate more severe failure. In general, beta-blocking agents should be avoided in patients with overt congestive failure However, in some patients with compensated cardiac failure it may be necessary to utilize them. In such a situation, they must be used cautiously. In Patients Without a History of Cardiac Failure Continued depression of the myocardium with beta-blockers can, in some patients, precipitate cardiac failure At the first signs or symptoms of heart failure, discontinuation of bisoprolol fumarate should be considered.

The patient is having a hemodialysis session and is on fast AF with a heart rate of 150 but stable blood pressure, and is already on bisoprolol 10 mg. The patient is known to have right heart failure.

• The patient's current condition of fast AF and right heart failure requires careful consideration of the use of beta-blockers like bisoprolol.
• Given that the patient is already on bisoprolol 10 mg, it is essential to monitor the patient's condition closely for any signs of worsening heart failure or other adverse effects.
• No changes to the bisoprolol dose should be made without careful consideration of the potential risks and benefits, and close monitoring of the patient's condition.
• It is crucial to consult a physician before making any changes to the patient's treatment plan 2.

From the Research

Patient Management

The patient is currently undergoing hemodialysis and is experiencing fast atrial fibrillation (AF) with a heart rate of 150, but has stable blood pressure and has already received 10mg of bisoprolol. The patient is also known to have right heart failure.

Current Treatment

• The patient has already received bisoprolol, a beta-blocker, which has been shown to be effective in controlling heart rate in patients with atrial fibrillation 3, 4.
• Beta-blockers, such as bisoprolol, are commonly used for rate control in atrial fibrillation and have been shown to be effective in reducing symptoms and improving quality of life 3, 4.

Alternative Treatment Options

• Calcium channel blockers, such as verapamil and diltiazem, can also be used for rate control in atrial fibrillation, but may have negative inotropic effects and can exacerbate heart failure 5.
• The choice between beta-blockers and calcium channel blockers depends on the individual patient's characteristics and medical history 6, 7.

Considerations for Right Heart Failure

• Patients with right heart failure may require careful management of their heart rate and rhythm to prevent further deterioration of their condition 5.
• Beta-blockers, such as bisoprolol, may be a good option for these patients, as they can help to reduce heart rate and improve symptoms without exacerbating heart failure 3, 4.

Monitoring and Adjustment

• The patient's heart rate and rhythm should be closely monitored, and adjustments to their treatment should be made as needed to ensure adequate rate control and prevent complications 7.
• The patient's response to bisoprolol should be evaluated, and the dose may need to be adjusted or alternative treatments considered if the patient's heart rate and symptoms are not adequately controlled 3, 4.