What is the best management approach for a 65-year-old female patient with cardiomegaly, atrial fibrillation, bifascicular block, reduced ejection fraction (45%), and pulmonary congestion, who is not currently taking any medications?

Management of 65-Year-Old Female with Cardiomegaly, Atrial Fibrillation, Bifascicular Block, 45% Ejection Fraction, and Pulmonary Congestion

This patient requires immediate hospitalization for acute decompensated heart failure with aggressive diuretic therapy, initiation of guideline-directed medical therapy for heart failure with reduced ejection fraction, rate control for atrial fibrillation using beta-blockers (avoiding calcium channel blockers), and anticoagulation for stroke prevention. 1

Immediate Acute Management

Diuretic Therapy for Pulmonary Congestion

• Initiate intravenous loop diuretics immediately to relieve pulmonary congestion and reduce extracellular fluid volume excess 1
• The initial intravenous dose should equal or exceed any chronic oral daily dose if the patient were previously on diuretics 1
• Monitor urine output, vital signs, body weight (measured at the same time each day), and clinical signs of congestion serially, titrating the diuretic dose accordingly 1
• Measure daily serum electrolytes, urea nitrogen, and creatinine concentrations during IV diuretic use 1
• If diuresis is inadequate, intensify the regimen by using higher doses of loop diuretics, adding a second diuretic (metolazone, spironolactone, or IV chlorothiazide), or using continuous infusion of loop diuretics 1

Hemodynamic Monitoring

• Perform invasive hemodynamic monitoring if the patient is in respiratory distress or if the adequacy of intracardiac filling pressures cannot be determined from clinical assessment 1
• If clinical evidence of hypotension with hypoperfusion exists alongside elevated cardiac filling pressures, administer intravenous inotropic or vasopressor drugs to maintain systemic perfusion while considering more definitive therapy 1

Atrial Fibrillation Management

Rate Control Strategy

• Initiate beta-blocker therapy (metoprolol succinate or bisoprolol) as the first-line agent for rate control in this patient with reduced ejection fraction (45%) 1, 2
• Beta-blockers are mandatory in heart failure with reduced ejection fraction as they improve morbidity and mortality 1
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) entirely as they are Class III (harm) in heart failure with reduced ejection fraction, increasing risk of heart failure worsening and hospitalization 1, 3
• Target lenient rate control with resting heart rate <110 bpm initially, with stricter control (<80 bpm) if symptoms persist 1, 2
• If beta-blocker monotherapy fails to achieve adequate rate control, add digoxin for combination therapy 1, 2
• IV amiodarone can be used acutely if other measures are unsuccessful or contraindicated, as it provides both rate and rhythm control with minimal negative inotropic effects 3, 4

Anticoagulation for Stroke Prevention

• Calculate CHA₂DS₂-VASc score immediately: This patient scores at minimum 3 points (age 65-74 = 1 point, heart failure = 1 point, female sex = 1 point), mandating anticoagulation 1, 2
• Initiate a direct oral anticoagulant (DOAC) such as apixaban, rivaroxaban, edoxaban, or dabigatran as preferred over warfarin due to lower risk of intracranial hemorrhage 1, 2
• Standard dosing for apixaban is 5 mg twice daily, or 2.5 mg twice daily if the patient meets dose-reduction criteria (age ≥80 years, weight ≤60 kg, or creatinine ≥1.5 mg/dL—any 2 of 3 factors) 2
• If warfarin is used instead, maintain INR between 2.0-3.0 with weekly monitoring during initiation and monthly when stable 1, 2
• Continue anticoagulation indefinitely regardless of whether sinus rhythm is restored, as stroke risk persists based on underlying risk factors 1, 2, 4

Rhythm Control Considerations

• Do not pursue immediate cardioversion unless the patient becomes hemodynamically unstable 1, 2
• If atrial fibrillation duration is >48 hours or unknown (likely in this case), therapeutic anticoagulation for at least 3 weeks is required before elective cardioversion 1, 2
• Rate control with anticoagulation is the appropriate initial strategy for most patients, as rhythm control offers no survival advantage and causes more hospitalizations and adverse drug effects 2, 4, 5

Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction

Essential Medications to Initiate Before Discharge

This patient requires four classes of medications that each independently reduce mortality by at least 20%: 1

1. ACE inhibitor or ARB (or preferably sacubitril/valsartan if hemodynamically stable)

   • Initiate in stable patients prior to hospital discharge 1
   • These agents are effective in lowering blood pressure and reducing mortality in heart failure with reduced ejection fraction 1

2. Beta-blocker (carvedilol, metoprolol succinate, or bisoprolol)

   • Initiate after optimization of volume status and successful discontinuation of IV diuretics, vasodilators, and inotropic agents 1
   • Start at a low dose in stable patients and uptitrate gradually 1
   • Metoprolol succinate has been shown to improve survival in heart failure with reduced ejection fraction 6

3. Mineralocorticoid receptor antagonist (spironolactone or eplerenone)

   • Should be included if heart failure with reduced ejection fraction (<40%) is present 1
   • Do not use if serum creatinine ≥2.5 mg/dL in men or ≥2.0 mg/dL in women, or if serum potassium ≥5.0 mEq/L 1
   • Monitor serum potassium frequently when administered with ACE inhibitor or ARB 1

4. SGLT2 inhibitor (if evidence base is confirmed at time of treatment)

   • Consider as part of comprehensive cardiometabolic risk factor management 1

Medication Titration Strategy

• Use a forced-titration strategy to achieve and maintain specified target doses over time 1
• Initiate therapy at low doses and uptitrate gradually based on tolerance 1
• Continue these therapies even during symptomatic exacerbations requiring hospitalization, in the absence of hemodynamic instability or contraindications 1, 7

Special Considerations

Bifascicular Block Management

• The presence of bifascicular block does not contraindicate beta-blocker therapy, but requires careful monitoring for bradycardia 1
• Monitor with ambulatory ECG to check for bradycardia when combining rate-control agents 1
• Consider pacemaker evaluation if symptomatic bradycardia develops or if AV node ablation becomes necessary for refractory rate control 1

Transition to Oral Therapy

• Transition from intravenous to oral diuretic therapy with careful attention to oral diuretic dosing and monitoring of electrolytes 1
• Monitor for supine and upright hypotension, worsening renal function, and heart failure signs/symptoms with all medication changes 1
• In severe heart failure (NYHA class III-IV) or severe renal impairment (eGFR <30 mL/min), loop diuretics should be used for volume control 1

Discharge Planning and Follow-Up

Comprehensive Discharge Instructions

Provide written discharge instructions emphasizing six critical aspects: 1

• Diet (sodium and fluid restriction)
• Discharge medications with focus on adherence and uptitration to target doses
• Activity level
• Follow-up appointments
• Daily weight monitoring
• What to do if heart failure symptoms worsen

Post-Discharge Monitoring

• Arrange follow-up within 7-14 days of discharge to assess medication tolerance and clinical status 1
• Evaluate at 6 months after presentation, then at least annually or based on clinical need 1
• Monitor renal function at least annually when using DOACs, more frequently if clinically indicated 2
• Continue uptitration of guideline-directed medical therapy to target doses in the outpatient setting 1

Common Pitfalls to Avoid

• Never use diltiazem or verapamil in this patient with reduced ejection fraction, as they cause harm 1, 3
• Do not delay initiation of guideline-directed medical therapy until after discharge; stable patients should have these medications started in-hospital 1, 7
• Do not discontinue beta-blockers during hospitalization unless hemodynamic instability is present 1, 7
• Do not use digoxin as the sole agent for rate control in atrial fibrillation 2
• Do not stop anticoagulation if sinus rhythm is restored, as stroke risk persists based on CHA₂DS₂-VASc score 1, 2
• Do not underdose anticoagulation or inappropriately discontinue it, as this increases stroke risk 2
• Avoid combining anticoagulants with antiplatelet agents unless specifically indicated for acute vascular event 1