This handout is for acute decompensated hf complicated by atrial fibrillation with rapid ventricular response. Your care team identified this based on: adhf presentation + af on ecg with hr ≥110 bpm — composite engine activates.
Other reasons your team may use this plan: known hf patient + new af-rvr (hr ≥110) on 12-lead ecg → mutually-amplifying decompensation; elevated nt-probnp for age + af-rvr — composite physiology (loss of atrial kick + tachycardia-mediated).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| furosemide | IV bolus 2-2.5× home dose (e.g. 80-160 mg IV); if naïve 80 mg IV | IV | q12h or continuous 5-20 mg/h | DOSE PMID 21366472 — high-dose intermittent IV loop reasonable; assess UOP at 2h |
| metoprolol_iv | 5 mg IV q5 min × 3 doses; titrate to HR <110 lenient or <80 strict if symptomatic | IV | q5 min × 3 then PO BID | ACC/AHA 2024 AF Class I; preferred over diltiazem in HFrEF (negative inotrope); transition to oral metoprolol succinate for chronic GDMT in HFrEF |
| digoxin | 0.25 mg IV load, then 0.125 mg IV q6h × 2-3 doses; PO maintenance 0.125 mg daily | IV → PO | load + daily | ACC/AHA 2024 AF Class IIa — digoxin in HFrEF + AF-RVR when BB inadequate or hypotension limits BB; target trough 0.5-0.9 ng/mL |
| diltiazem | 0.25 mg/kg IV bolus over 2 min; infusion 5-15 mg/h | IV | bolus + infusion | ACC/AHA 2024 AF Class I for HFpEF; RELATIVELY CONTRAINDICATED in HFrEF (negative inotrope worsens decompensation) |
| amiodarone | 150 mg IV bolus over 10 min → 1 mg/min × 6 h → 0.5 mg/min | IV | continuous infusion × 24 h then PO | ACC/AHA 2024 AF Class IIa; reserve for refractory rate or rhythm control given long half-life + multi-organ tox; useful when DCCV not feasible or HFrEF with refractory rates |
| magnesium_sulfate | 2 g IV bolus; repeat × 1 if Mg <2 | IV | bolus | Mg ≥2 suppresses AF + supports rate control; intracellular Mg often depleted in HF |
| apixaban | 5 mg BID (or 2.5 BID if ≥2 of: Cr ≥1.5, age ≥80, weight ≤60) | PO | BID | ARISTOTLE PMID 21870978; ACC/AHA 2024 AF Class I — apixaban preferred in HF + AF cohort given best efficacy + bleed profile |
| sacubitril-valsartan | 24/26 mg BID; up-titrate per STRONG-HF | PO | BID | PIONEER-HF PMID 30403955 — in-hospital ARNI safe; PARADIGM-HF mortality benefit; initiate after compensation in composite |
| empagliflozin | 10 mg PO daily | PO | daily | EMPULSE PMID 35347356 — empagliflozin in acute HF improves clinical benefit; continue after discharge |
Plan: ADHF + AF-RVR composite — EF-stratified rate control + decongestion + DOAC + in-hospital GDMT
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Cardiology + EP at 1 week per STRONG-HF; ablation candidacy assessment per CASTLE-AF (consider after compensated, especially HFrEF); chronic AC continuation; chronic the four foundational heart-failure medications up-titration; thyroid follow-up if abnormal
Guideline: 2024 ACC/AHA/ACCP/HRS AF Guideline + 2022 AHA/ACC/HFSA HF Guideline (with 2023 Focused Update)