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cardio.acute-hf.with-af-rvr.v1PRODUCTION
cardio.acute-hf.with-af-rvr.v1

Acute decompensated HF complicated by atrial fibrillation with rapid ventricular response

cardiologyacuteadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Composite engine: ADHF + AF-RVR mutually amplify (loss of atrial kick + tachycardia-mediated reduced diastolic filling vs atrial stretch + neurohormonal activation); both engines must run; route to cardio.acute-hf.core.v1 for decongestion + cardio.afib.core.v1 for chronic rate/rhythm/AC

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Advance rule
Set
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composite physiology confirmed

Patient inputs (15)

Hyperthyroidism is classic reversible AF precipitant — must screen at first presentation

Age drives CHA₂DS₂-VASc stroke risk + DOAC dose adjustment + lenient vs strict rate target

Defines RVR (≥110 bpm); rate target lenient <110 per RACE II if EF preserved + asymptomatic; strict <80 if symptomatic

eGFR for DOAC dose (apixaban 2.5 BID if 2 of 3 criteria; dabigatran avoid <30); diuretic dosing

Goal K ≥4 to suppress AF; MRA + ARNI dosing risk; arrhythmogenic if low

Goal Mg ≥2 to suppress AF; empiric repletion in decompensation

On AC vs not changes DCCV strategy + bleed risk; check INR if warfarin, last DOAC dose timing

EF stratifies drug choice — diltiazem relatively contraindicated in HFrEF; digoxin + metoprolol preferred; LA size for ablation candidacy per CASTLE-AF

12-lead confirms AF-RVR (irregularly irregular without P waves), excludes flutter, screens for ischemic ECG as composite precipitant

Confirms HF component + decongestion target; trended to assess response

Ischemia as composite precipitant; demand ischemia from RVR can drive type-2 NSTEMI

HD-unstable (SBP <90 + AF-RVR) → STAT DCCV per ACC/AHA 2024 Class I; SCAI staging if persistent

Hypoxia from pulmonary edema + tachycardia-mediated reduced filling; NIPPV indication per 3CPO

Beyond AF — thyroid, ischemia, infection, NSAID, EtOH, non-adherence drive co-management

Stroke risk stratification — nearly always ≥2 in HF cohort (HF=+1, age≥65=+1-2); drives DOAC initiation

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (4)

4 need judgement
  • informationallife_threateninghd_unstable_af_rvr_with_adhf
    Composite + SBP <90 + worsening congestion despite IV rate control — HD-unstable
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcomposite_with_cardiogenic_shock
    Composite + SBP <90 + lactate ≥2 + end-organ dysfunction (SCAI C+)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmultimodal_decompensation_with_thyroid_storm
    Composite + TSH <0.01 + free T4 elevated + tachycardia disproportionate → thyroid storm precipitant
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererate_refractory_with_worsening_congestion
    AF-RVR HR >120 sustained despite IV BB + digoxin AND congestion not improving on IV diuretic at 6-12 h
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

ADHF + AF-RVR composite — EF-stratified rate control + decongestion + DOAC + in-hospital GDMT
axis: adhf_af_rvr_composite_phenotype
Selected axis "ADHF + AF-RVR composite — EF-stratified rate control + decongestion + DOAC + in-hospital GDMT" by default fallback (first axis)
  • furosemide
    first line
    loop_diuretic
    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
    triggers: volume_overload, composite_decompensation
    DOSE PMID 21366472 — high-dose intermittent IV loop reasonable; assess UOP at 2h
    rxcui 4603
  • metoprolol_iv
    first line
    beta1_selective_blocker
    5 mg IV q5 min × 3 doses; titrate to HR <110 lenient or <80 strict if symptomatic • IV • q5 min × 3 then PO BID
    triggers: af_rvr_with_adequate_bp, preserved_or_reduced_ef
    ACC/AHA 2024 AF Class I; preferred over diltiazem in HFrEF (negative inotrope); transition to oral metoprolol succinate for chronic GDMT in HFrEF
    rxcui 6918
  • digoxin
    second line
    cardiac_glycoside
    0.25 mg IV load, then 0.125 mg IV q6h × 2-3 doses; PO maintenance 0.125 mg daily • IV → PO • load + daily
    triggers: hfref_with_persistent_rvr_after_iv_metoprolol, hypotensive_unable_to_use_bb
    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
    rxcui 3407
  • diltiazem
    comorbidity specific
    non_dihydropyridine_ccb
    0.25 mg/kg IV bolus over 2 min; infusion 5-15 mg/h • IV • bolus + infusion
    triggers: af_rvr_with_preserved_ef_only_no_hfref, bb_intolerant
    ACC/AHA 2024 AF Class I for HFpEF; RELATIVELY CONTRAINDICATED in HFrEF (negative inotrope worsens decompensation)
    rxcui 3443
  • amiodarone
    rescue
    antiarrhythmic_class_iii
    150 mg IV bolus over 10 min → 1 mg/min × 6 h → 0.5 mg/min • IV • continuous infusion × 24 h then PO
    triggers: rate_refractory_to_bb_plus_digoxin, rhythm_control_when_dccv_not_feasible
    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
    rxcui 203114
  • magnesium_sulfate
    first line
    electrolyte_repletion
    2 g IV bolus; repeat × 1 if Mg <2 • IV • bolus
    triggers: composite_decompensation, low_or_borderline_mg
    Mg ≥2 suppresses AF + supports rate control; intracellular Mg often depleted in HF
    rxcui 6585
  • apixaban
    first line
    doac_factor_xa_direct
    5 mg BID (or 2.5 BID if ≥2 of: Cr ≥1.5, age ≥80, weight ≤60) • PO • BID
    triggers: cha2ds2_vasc_ge_2_in_composite, af_with_hf
    ARISTOTLE PMID 21870978; ACC/AHA 2024 AF Class I — apixaban preferred in HF + AF cohort given best efficacy + bleed profile
    rxcui 1364430
  • sacubitril-valsartan
    first line
    arni
    24/26 mg BID; up-titrate per STRONG-HF • PO • BID
    triggers: hfref_post_compensation, sbp_ge_100_after_decongestion
    PIONEER-HF PMID 30403955 — in-hospital ARNI safe; PARADIGM-HF mortality benefit; initiate after compensation in composite
    rxcui 1656328
  • empagliflozin
    first line
    sglt2_inhibitor
    10 mg PO daily • PO • daily
    triggers: hfref_or_hfpef_with_egfr_above_20
    EMPULSE PMID 35347356 — empagliflozin in acute HF improves clinical benefit; continue after discharge
    rxcui 1545653

outpatient playbook — drug actions (2)

  1. 1. continue 4-pillar GDMT
    rxcui 1545653
    empagliflozin 10 + carvedilol + ARNI + MRA at target • PO • as scheduled
    trigger: HFrEF
    ACC/AHA 2022 HF Class I
  2. 2. continue DOAC lifelong
    rxcui 1364430
    apixaban 5 BID • PO • BID
    trigger: CHA₂DS₂-VASc ≥2
    ARISTOTLE — lifelong stroke prevention

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ADHF presentation + AF on ECG with HR ≥110 bpm — composite engine activates; 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute decompensated HF complicated by atrial fibrillation with rapid ventricular response** (cardio.acute-hf.with-af-rvr.v1).
Phenotype framing: Stratify by EF — HFrEF (EF <40) vs HFmrEF (40-49) vs HFpEF (≥50) drives drug choice (diltiazem avoided in HFrEF; digoxin + metoprolol preferred); LA size + AF duration drive ablation candidacy per CASTLE-AF
Scope: Composite engine: ADHF + AF-RVR mutually amplify (loss of atrial kick + tachycardia-mediated reduced diastolic filling vs atrial stretch + neurohormonal activation); both engines must run; route to cardio.acute-hf.core.v1 for decongestion + cardio.afib.core.v1 for chronic rate/rhythm/AC

No severity triggers fired against current inputs.

Plan

Regimen axis: **ADHF + AF-RVR composite — EF-stratified rate control + decongestion + DOAC + in-hospital GDMT**.
1. 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 (loop_diuretic, first line) — DOSE PMID 21366472 — high-dose intermittent IV loop reasonable; assess UOP at 2h
2. 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 (beta1_selective_blocker, first line) — ACC/AHA 2024 AF Class I; preferred over diltiazem in HFrEF (negative inotrope); transition to oral metoprolol succinate for chronic GDMT in HFrEF
3. 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 (cardiac_glycoside, second line) — 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
4. diltiazem 0.25 mg/kg IV bolus over 2 min; infusion 5-15 mg/h IV bolus + infusion (non_dihydropyridine_ccb, comorbidity specific) — ACC/AHA 2024 AF Class I for HFpEF; RELATIVELY CONTRAINDICATED in HFrEF (negative inotrope worsens decompensation)
5. amiodarone 150 mg IV bolus over 10 min → 1 mg/min × 6 h → 0.5 mg/min IV continuous infusion × 24 h then PO (antiarrhythmic_class_iii, rescue) — 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
6. magnesium_sulfate 2 g IV bolus; repeat × 1 if Mg <2 IV bolus (electrolyte_repletion, first line) — Mg ≥2 suppresses AF + supports rate control; intracellular Mg often depleted in HF
7. apixaban 5 mg BID (or 2.5 BID if ≥2 of: Cr ≥1.5, age ≥80, weight ≤60) PO BID (doac_factor_xa_direct, first line) — ARISTOTLE PMID 21870978; ACC/AHA 2024 AF Class I — apixaban preferred in HF + AF cohort given best efficacy + bleed profile
8. sacubitril-valsartan 24/26 mg BID; up-titrate per STRONG-HF PO BID (arni, first line) — PIONEER-HF PMID 30403955 — in-hospital ARNI safe; PARADIGM-HF mortality benefit; initiate after compensation in composite
9. empagliflozin 10 mg PO daily PO daily (sglt2_inhibitor, first line) — EMPULSE PMID 35347356 — empagliflozin in acute HF improves clinical benefit; continue after discharge

Setting playbook (outpatient) — Long-term cardiology + EP surveillance: DOAC continuation, GDMT maintenance, ablation completion if pursued, ICD eligibility re-evaluation at 90 days, secondary prevention
10. continue 4-pillar GDMT empagliflozin 10 + carvedilol + ARNI + MRA at target PO as scheduled — HFrEF (ACC/AHA 2022 HF Class I)
11. continue DOAC lifelong apixaban 5 BID PO BID — CHA₂DS₂-VASc ≥2 (ARISTOTLE — lifelong stroke prevention)

Non-pharmacologic actions:
- Ablation if pursued per CASTLE-AF
- Cardiac rehab maintenance
- Lifestyle: weight loss, OSA treatment, EtOH limit (LEGACY trial)

AVOID / contraindication checks:
- Diltiazem_avoid_hfref (ACC/AHA 2024 AF + 2022 HF — negative inotrope worsens decompensation)
- Apixaban_dose_reduce_if_2_of_3 (Cr ≥1.5, age ≥80, weight ≤60)
- Dabigatran_avoid_egfr_lt_30
- Digoxin_target_trough_0.5_to_0.9_ng_ml (ARISTOTLE post hoc; lower trough preferred in HFrEF)
- Amiodarone_avoid_severe_qt_prolongation
- Metoprolol_iv_avoid_severe_bradycardia_or_high_grade_av_block

Monitoring

Regimen monitoring:
- continuous telemetry during rate control and post dccv
- serial k mg q12h during diuresis to keep k 4 mg 2
- daily bmp during diuresis
- nt probnp trend to assess decongestion
- tsh at baseline and 4 weeks if abnormal
- doac adherence check at 1 week and 4 weeks
- echo at 3 months to reassess ef for icd eligibility

Setting (outpatient) monitoring:
- Quarterly + annual EF + lipid + AF burden

Follow-up plan: Cardiology + EP at 1 week per STRONG-HF; ablation candidacy assessment per CASTLE-AF (consider after compensated, especially HFrEF); chronic AC continuation; chronic GDMT up-titration; thyroid follow-up if abnormal
- Close-out criterion: AC continued + cardiology + EP + thyroid follow-up booked + ablation referral if HFrEF + persistent AF

Monitoring phase: Continuous telemetry; daily weight, I/O, BMP q24h with K + Mg repletion; NT-proBNP trend; HR target lenient <110 per RACE II if asymptomatic; INR or DOAC adherence; TSH trend if hyperthyroid

Disposition

Current setting: outpatient — Long-term cardiology + EP surveillance: DOAC continuation, GDMT maintenance, ablation completion if pursued, ICD eligibility re-evaluation at 90 days, secondary prevention

Disposition criteria:
- Long-term continuation; hand off to cardio.hf.core.v1 + cardio.afib.core.v1 chronic engines

Escalation triggers (move to higher acuity):
- AF burden increasing despite ablation → repeat ablation evaluation
- GDMT intolerance → adjust per kidney/K trajectory
- Bleeding on DOAC → reverse + reassess CHA₂DS₂-VASc vs HAS-BLED

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Composite + SBP <90 + worsening congestion despite IV rate control — HD-unstable
- [LIFE_THREATENING] Composite + SBP <90 + lactate ≥2 + end-organ dysfunction (SCAI C+)
- [LIFE_THREATENING] Composite + TSH <0.01 + free T4 elevated + tachycardia disproportionate → thyroid storm precipitant

Citations

- 2024 ACC/AHA/ACCP/HRS AF Guideline + 2022 AHA/ACC/HFSA HF Guideline (with 2023 Focused Update) [PMID:38753446](https://pubmed.ncbi.nlm.nih.gov/38753446/)
- Cited evidence (PMID 35363499) [PMID:35363499](https://pubmed.ncbi.nlm.nih.gov/35363499/)
- Cited evidence (PMID 38264914) [PMID:38264914](https://pubmed.ncbi.nlm.nih.gov/38264914/)
- Cited evidence (PMID 29385358) [PMID:29385358](https://pubmed.ncbi.nlm.nih.gov/29385358/)
- Cited evidence (PMID 30883054) [PMID:30883054](https://pubmed.ncbi.nlm.nih.gov/30883054/)

Last reconciled with current guidelines: 2026-05-14.
References