HPI

• A 63 year old man with history of HFrEF (EF=15-20%), diabetes, hypertension, prior CVA, atrial fibrillation on Xarelto, CKD presents with shortness of breath
• Pt reports 4 days of increasing shortness of breath, which worsened overnight 
• +DOE, orthopnea, productive cough, and bilateral LE edema
• Recently stopped diuretics

Exam

Vital signs: HR 147, BP 210/133, RR 32, SpO2 100%, T 97.6

• General: mild distress, AAOx3
• Heart: tachycardic and irregular
• Lungs: increased work of breathing with tachypnea, belly breathing, retractions. Scattered crackles bilaterally
• Extremities: bilateral 1+ pitting edema to the knee
  

ECG

Diagnosis

• Atrial fibrillation with RVR, CHF exacerbation in the setting of medication changes

Management

1. Administered 2 doses of 0.4 mg sublingual nitroglycerin to reduce afterload and improve CHF symptoms given high blood pressure in setting of CHF exacerbation. Blood pressure improved to 180s/110s, HR remains 150s, mild improvement of WOB

2. After afterload reduction, administered 20 mg IV diltiazem for rate control of atrial fibrillation. Improvement of rate to the 90s with decrease in blood pressure to 150s/90s

3. After improvement of rate, gave 40 IV Lasix for diuresis

4. Consulted cardiology and admitted to the cardiac step down unit for management of CHF and atrial fibrillation

Pearls

• The rapid rate in a fib with RVR can be a compensatory tachycardia for another process (such as poor cardiac output due to CHF exacerbation or sepsis)
• Before treating rate primarily, make sure you search for and address any underlying causes, as a patient may decompensate otherwise
• Rate control can be achieved with beta blockers (such as metoprolol) or calcium channel blockers (such as diltiazem)
• Rate over rhythm control is usually chosen for symptomatic but hemodynamically stable patients
• In CHF exacerbation with severely elevated blood pressure, nitrates should precede diuretics to decrease afterload
• Sublingual nitro is a fast acting medication that can be used for afterload reduction in CHF without setting up a drip

References:

Ganz., et al. “Control of ventricular rate in atrial fibrillation: Pharmacologic therapy.” UpToDate. January 2021

Storrow, et al. “Acute Heart Failure.” Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 9th Edition.” (367-374). 2020.