GP refers youngish patient with 3 months of increasing dyspnea, now even some at rest, and new AF. Sedate lifestyle, overweight.
On examination ECG with AF, HR 135. Bp 130/80. Some oedema. #POCUS shows something like the following #cardioed #FOAMed Poll below.

Additionally fixed dilated IVC, small bilateral pleural effusions. What is your first therapeutic intervention? (Don't get caught up in the details of the #POCUS-loop, it is only meant to illustrate AF with severely reduced systolic function)

Thanks for all the votes! Diuretics won in the poll, I'll go through my thinking in these cases

First of all, while clearly the patient has severe heart failure, he is not unstable or critically ill. (I could have made that clearer in the case to start with ). As such, we are not in a rush. 1/x

What is the treatment goal here? The immediate symptoms is from congestion, not low cardiac output. Remember, EF is SV normalised for EDV. A dilated LV with a very low EF can have a normal SV. In addition or HR can compensate for low SV. 2/x

This get's to the heart of one of my learning point here. We should not think differently about AF with high HR than with sinus tachycardia. First think of it a secondary and compensatory to something else. Here, probably low stroke volume and volume overload. 3/x

Remember, total load = preload + afterload and is the force the LV must overcome to contract. This is why I think there is a decending limb on the Frank-Starling curve (contested, I know). Reducing preload can reduce total load and thus increase stroke volume. 4/x

@fluidloading and @Rhazelovitch exemplified what could happen if rate control is attempted. Rate control drugs in general both reduce contractility and rate, both of which can be detrimental if HR is compensatory and contractility reduced. https://twitter.com/Rhazelovitch/status/1143155831120322561 5/x

Similar cases here is the reason why I never give a rate reducing drug without #POCUS first. Here's another example where B-blockers probably led to a stable patient going into cariogenic shock. https://twitter.com/LMSaxhaug/status/1125480556773429248 6/x

Again, think of sinus tachycardia and rapid AF primarily as secondary and compensatory first and foremost. Don't fall into the trap of trying to normalise the patients physiological variables, think about the underlying pathophysiology and treat that. 7/x

Here's a wonderful paper by Kavanagh on the pitfalls of normalising values, that really resonated with me. I'm sorry I never heard of it until the author's passing. https://link.springer.com/article/10.1007%2Fs00134-005-2729-7#Fig1 Thank you for sharing it @fluidloading! 8/x

And rythm controll? Cardioversion should certainly be attempted at some point, particularly as arrhythmia-induced cardiomyopathy is a possibility. Another indication would be if the patient was unstable. We would probably attempt it next day after TEE. https://twitter.com/LMSaxhaug/status/1143413924521529345control 9/x

So my approach would be very close to that of @fluidloading. If not in respiratory distress or haemodynamically unstable, I would simply start with diuretics, and in my experience that will often have a positive effect on heart rate as well. https://twitter.com/fluidloading/status/1143153197529423872 10/x

Lastly I can't really speak to digoxin as I have no experience with it. It is no longer in use at my hospital. We used to have digitoxin in Norway, when it was discontinued most patients were switched to B/Ca-blockers and digoxin never caught on. 11/x

To summarise:
Stable patients do not need rapid aggressive interventions

Don't treat heart rate unless your sure it is not compensatory. Focus on the cause.

More broadly, don't assume deviating physiological values are necessarily maladaptive and need correction.
12/12

@f_g_zampieri @kyliebaker888 @DrDavidPalmer @siddharth_dugar @jtanguay11 @mjbeyak @marcelo_zapata @DiebelLucas @stephen08002294

I actually have to say I'm surprised so many favoured rate control and so few rhythm control/cardioversion.