Decompensated Heart Failure with Atrial Fibrillation

Explanation

This man has acutely decompensated heart failure with volume overload, evidenced by orthopnoea, raised jugular venous pressure, peripheral oedema, crackles, and a transudative pleural effusion. The initial priority is decongestion with an intravenous loop diuretic such as furosemide, together with vasodilators if blood pressure permits, because relieving congestion improves symptoms, gas exchange, and renal perfusion. Intravenous rather than oral dosing is used because gut wall oedema impairs absorption in the congested state, and the response is titrated against urine output, daily weights, and electrolytes. His ventricular rate of 96 beats/min is already acceptable, and lenient rate control below 110 beats/min is adequate in permanent atrial fibrillation, so escalating rate-control therapy is unnecessary. A digoxin level of 1.4 ng/mL is at the upper end of the therapeutic range for heart failure, where 0.5 to 0.9 ng/mL is targeted; increasing the dose in an 82-year-old with likely reduced renal clearance risks toxicity with nausea, visual halos, and arrhythmia. Non-dihydropyridine calcium channel blockers such as verapamil and diltiazem are negatively inotropic and are contraindicated in decompensated heart failure with reduced ejection fraction. Electrical cardioversion is indicated only for haemodynamic instability or when a rhythm control strategy is chosen after adequate anticoagulation, and in permanent atrial fibrillation with a dilated atrium sinus rhythm is unlikely to be maintained. Beta blockade should be reintroduced only after the patient is euvolaemic and stabilised.

Why each option

A.

The digoxin level is already at the top of the therapeutic range and the rate is controlled; increasing the dose in an elderly patient risks toxicity.

B.

Verapamil is negatively inotropic and contraindicated in decompensated heart failure with reduced ejection fraction.

C.

Correct. Intravenous loop diuretic is the first-line treatment for acute congestion with orthopnoea, raised venous pressure, and pleural effusion.

D.

Cardioversion is reserved for haemodynamic instability or a planned rhythm-control strategy after adequate anticoagulation, not for volume overload.

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