New Fast Atrial Fibrillation in a Patient With HFrEF and a Recent Fall

I would not give IV diltiazem without a senior review, and I would say so.

Why not

• Non-dihydropyridine calcium channel blockers are negative inotropes and are avoided in HFrEF (EF 30%). Her output depends on the contractility she has left.
• She is already beta-blocked with carvedilol. Adding diltiazem risks bradycardia, hypotension, and precipitation of decompensation; the combination is also a recognised cause of heart block.
• Her BP of 118/72 is only adequate, and her light-headedness suggests she is not truly asymptomatic even if she is not in the classic "unstable" category.

What I would propose

• Treat precipitants first: infection, thyrotoxicosis, anaemia, volume overload, missed beta-blocker doses.
• Cautious rate control with additional oral carvedilol or small IV metoprolol aliquots, titrated against BP; digoxin or amiodarone as second-line with cardiology input.
• If she develops hypotension, ischaemic pain, pulmonary oedema or altered mentation, she becomes unstable and needs urgent synchronised cardioversion rather than more negatively inotropic drugs.

Reframing the scores

• A CHA2DS2-VASc of 5 is a high annual stroke risk. Strokes in AF are frequently large and disabling.
• HAS-BLED is not a score that decides whether to anticoagulate; it flags modifiable factors so they can be corrected. Using it as a veto is a common but incorrect application.

The fall

• A bruised forearm from a fall eight days ago is not a contraindication. The actionable question is why she fell: orthostasis from aggressive diuresis, sedatives, vision, footwear, alcohol, gait and balance, home hazards.
• Address each modifiable factor; consider a falls assessment and referral.

Recommendation

• Start a DOAC (typically apixaban given her age and renal function), dosed accurately after checking creatinine, weight and age. Confirm no interacting antiplatelets.
• Involve her in a shared decision: she fears "blood test clinics," so explain that apixaban needs infrequent monitoring compared with warfarin and that a once-daily alternative exists.
• Give written information, involve the daughter, and document the discussion and her preference.

Assessment: aberrancy versus VT

• In AF, a long-then-short R-R sequence can cause rate-related aberrancy (Ashman phenomenon), and the QRS morphology may resemble a typical bundle branch block.
• Against that: she has structural heart disease with an EF of 30%, where VT is common, and any wide-complex tachycardia should be presumed VT until proven otherwise.
• I would not give AV-nodal blocking drugs (verapamil, diltiazem, adenosine) for an undifferentiated wide-complex rhythm.

Immediate management

1. Stay with her, repeat BP, check perfusion, mentation and for chest pain; confirm the rhythm on a printed strip.
2. Apply defibrillator pads and ensure the crash trolley is nearby.
3. Capture a 12-lead during or immediately after the run; note the initiating sequence, QRS axis and whether it self-terminates.
4. Check potassium, magnesium, calcium, digoxin level if relevant, and review QT-prolonging drugs.
5. Notify the medical team; do not start an antiarrhythmic empirically on a self-terminating, asymptomatic 12-beat run.
6. If it becomes sustained with hypotension, ischaemia or reduced consciousness, synchronised cardioversion with sedation; defibrillation if pulseless.