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A 71-year-old man presents to his physician for follow-up of a recent emergency department visit. The patient has a 2-year history of mild congestive heart failure in the setting of long-standing hypertension. He reports that yesterday he sought care at the local emergency department for palpitations and shortness of breath. He was told that his heart was "fibrillating", but later, the fibrillation had "stopped on its own." His medications include a thiazide diuretic and an ACE inhibitor. On physical examination, he appears well and in no distress. His blood pressure is 130/80 mm Hg, and his pulse is 100/min and regular. His lungs have scant bibasilar rales, and no gallops are appreciated. He has a grade 2 holosystolic murmur heard best at the apex. His jugular venous pressure (JVP) is 10 cm at 30 degrees. An ECG taken in the office reveals atrial fibrillation at a rate of 94/min with normal ST segments. Which of the following is the most appropriate next step in management?
A. Discontinue the ACE inhibitor
B. Initiate amiodarone therapy
C. Initiate beta blocker therapy
D. Initiate digoxin therapy
E. Initiate furosemide therapy
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Digoxin is good for atrial fib and good for CHF.
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The correct answer is D.
An important concept to recognize in the treatment of medical conditions is that certain medications overlap syndromes and are efficacious in many areas. This "co-treatment" option maximizes the benefits of each drug in a regimen and often addresses two or more issues simultaneously. In this case, ACE inhibitors have been shown to be very beneficial in prolonging the survival of patients with congestive heart failure (CHF). They are also useful antihypertensive agents. Given this, discontinuing his ACE inhibitor (choice A) is clearly incorrect. This patient requires rate control for his atrial fibrillation, that, even at moderately elevated rates, causes cardiovascular embarrassment and pulmonary edema. Short of restoring this patient's atrial contractions, rate control is the best method to ensure adequate management of atrial fibrillation. Digoxin, with or without a nodal agent such as a beta blocker, has been shown to be reasonably effective at rate control.
Amiodarone therapy (choice B) is a pharmacologic method to convert atrial fibrillation to normal sinus rhythm. It has about the same efficacy as electrical cardioversion. It does nothing, however, in the short term, to control the rate.
Beta blocker therapy (choice C) alone is not as efficacious as digoxin alone. In addition, although some beta blockers (carvedilol) are being used clinically in CHF, not all beta blockers have been shown to be safe for use with this condition. Therefore, although digoxin plus a beta blocking agent would be preferred, there is good reason to initiate digoxin therapy alone for this patient.
Furosemide therapy (choice E) is partially correct. Although furosemide will help clinically with the failure, the underlying cause for the pulmonary edema will not be addressed solely by giving a diuretic. The more appropriate therapy is to control the rate, then the edema will resolve
