What is the initial management for a 58-year-old male with heart failure, an Ejection Fraction (EF) of 32%, and atrial fibrillation?

Management of Heart Failure with EF 32% and Atrial Fibrillation in a 58-Year-Old Male

This patient requires immediate initiation of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), rate control for atrial fibrillation using beta-blockers and/or digoxin, and anticoagulation for stroke prevention. 1

Immediate Anticoagulation

• Start a direct oral anticoagulant (DOAC) immediately as this patient has a CHA₂DS₂-VASc score ≥2 (heart failure = 1 point, age 58 = 0 points, but the presence of HFrEF alone mandates anticoagulation). 1
• DOACs are preferred over warfarin in eligible patients with HF and AF. 1
• Continue anticoagulation indefinitely regardless of whether rhythm or rate control strategy is pursued. 1

Rate Control Strategy for Atrial Fibrillation

Beta-blockers and/or digoxin are the only recommended first-line agents for rate control in patients with LVEF ≤40%. 1, 2

Specific medication approach:

• Start a beta-blocker (metoprolol succinate 25-50 mg daily, carvedilol 3.125 mg twice daily, or bisoprolol 1.25 mg daily) as these provide dual benefit for both HF and AF rate control. 1, 2
• Add digoxin 0.125-0.25 mg daily if beta-blocker alone does not achieve adequate rate control (target resting heart rate <110 bpm). 1, 2
• Avoid calcium channel blockers (diltiazem, verapamil) entirely—these are contraindicated due to negative inotropic effects that worsen outcomes in HFrEF. 1, 2

Rate control targets:

• Initial target: resting heart rate <110 bpm (lenient control). 1
• Pursue stricter control (<80 bpm) only if symptoms persist despite lenient control. 1

Guideline-Directed Medical Therapy for HFrEF

All four pillars of GDMT must be initiated and uptitrated rapidly:

1. ACE Inhibitor or ARB

• Start an ACE inhibitor (lisinopril 2.5-5 mg daily, enalapril 2.5 mg twice daily) or ARB if ACE inhibitor not tolerated. 1
• ACE inhibitors improve exercise capacity and may help maintain sinus rhythm if cardioversion is attempted. 3
• Uptitrate to target doses over 2-4 weeks as tolerated. 1

2. Beta-Blocker (already discussed above for rate control)

• Serves dual purpose: HF mortality reduction and AF rate control. 1

3. Mineralocorticoid Receptor Antagonist (MRA)

• Start spironolactone 12.5-25 mg daily given EF 32% and symptomatic HF. 1, 4
• Spironolactone reduced mortality by 30% in patients with EF ≤35% and NYHA class III-IV symptoms. 4
• Monitor potassium and creatinine closely—check at 1 week, 4 weeks, then every 3 months. 4
• Exclude if baseline creatinine >2.5 mg/dL or potassium >5.0 mEq/L. 4

4. SGLT2 Inhibitor

• Add dapagliflozin 10 mg daily or empagliflozin 10 mg daily regardless of diabetes status. 1
• Benefits are consistent in patients with concurrent AF. 5

Diuretic Therapy

• Initiate loop diuretic (furosemide 20-40 mg daily, torsemide 10-20 mg daily, or bumetanide 0.5-1 mg daily) if signs of volume overload present. 1
• If patient presents acutely decompensated, use IV furosemide at twice the home oral dose. 1, 6
• Torsemide may be preferred due to longer duration of action (12-16 hours vs 6-8 hours for furosemide). 1

Rhythm Control Consideration

Early rhythm control should be strongly considered in this relatively young patient (age 58) with new or recent-onset AF. 7, 5

• The EAST-AFNET 4 trial showed early rhythm control reduced cardiovascular outcomes in patients with AF and cardiovascular conditions including HF. 5
• Catheter ablation is superior to antiarrhythmic drugs in patients with HF and AF, improving survival, quality of life, ventricular function, and reducing HF hospitalizations. 7
• If pursuing rhythm control pharmacologically, amiodarone is the only safe antiarrhythmic in HFrEF, but catheter ablation should be preferred. 1, 7
• Refer to electrophysiology for ablation evaluation, particularly if symptoms persist despite rate control. 1, 7

Device Therapy Evaluation

Implantable Cardioverter-Defibrillator (ICD)

• Evaluate for primary prevention ICD if EF remains ≤35% after 3 months of optimal medical therapy and patient has reasonable expectation of survival >1 year with good functional status. 1
• ICD is indicated for NYHA class II-III symptoms with ischemic cardiomyopathy (≥40 days post-MI) or non-ischemic cardiomyopathy. 1

Cardiac Resynchronization Therapy (CRT)

• Consider CRT if QRS ≥120 msec (particularly ≥150 msec with LBBB morphology) and NYHA class II-IV symptoms despite optimal medical therapy. 1
• For patients with AF and EF ≤35%, CRT with or without ICD is reasonable if QRS ≥120 msec and NYHA class III-IV symptoms. 1
• If rate control fails and patient requires frequent ventricular pacing, AV node ablation with CRT-P or CRT-D is reasonable. 1

Critical Monitoring and Follow-up

• Check electrolytes (potassium, magnesium) and renal function within 1-2 weeks of starting GDMT, then regularly. 4
• Monitor for signs of worsening HF (weight gain, increased dyspnea, edema). 6
• Assess heart rate control at rest and with activity—adjust medications if symptomatic or HR >110 bpm at rest. 1
• Repeat echocardiogram in 3-6 months to reassess EF and guide device therapy decisions. 1

Common Pitfalls to Avoid

• Never use calcium channel blockers (diltiazem, verapamil) for rate control in HFrEF—they worsen outcomes. 1, 2
• Do not delay GDMT initiation—all four pillars should be started rapidly, not sequentially. 1
• Avoid excessive diuresis leading to hypotension that prevents uptitration of life-saving GDMT. 1
• Do not use combination of ACE inhibitor + ARB + MRA—this is harmful due to hyperkalemia and renal dysfunction risk. 1
• Do not withhold anticoagulation based on perceived bleeding risk without formal assessment—stroke risk is substantial. 1
• Patients with AF and HFrEF have worse outcomes than those with either condition alone, requiring aggressive management of both. 8, 9