John P. DiMarco

A trial fibrillation (AF) is a common rhythm in patients with acute decompensated heart failure (ADHF). Registry and trial data 1,2 indicate that 20% to 35% of patients with ADHF who are admitted to the hospital will be in AF at presentation. In about one third of these patients, the AF will be of recent onset. Despite the high frequency with which the combination of AF and ADHF is encountered, there are few published data that specifically address this problem. AF and worsening heart failure interact in a dangerous pattern. The adverse effects of AF in patients with heart failure may include loss of atrial transport, rapid and irregular ventricular rates, and toxic effects of antiarrhythmic drug therapy. Worsened heart failure, in turn, leads to increased atrial stretch and heightened sympathetic tone. These latter changes make the AF more resistant to treatment using either a rate-control or a rhythm-control strategy (Figure 1). The immediate general goals of therapy in ADHF are to improve symptoms, restore oxygenation, improve organ perfusion, and limit cardiac and renal injury. 3 In patients with sinus rhythm and ADHF, the appropriate use of vasodilators, oxygen, diuretics, positive inotropic agents, and mechanical devices to support ventilation or cardiac output forms the cornerstone of therapy. In patients who present with AF, however, additional treatment decisions are required.

PSVT is significant mainly for rapid heart rate. Prominent jugular venous pulsations due to atrial contraction against closed AV valves may be a clue to AVNRT. History, physical exam, and an ECG constitute an ap- propriate initial evaluation. Further di- agnostic studies are indicated only if there are signs or symptoms that sug- gest structural heart disease. A 12-lead ECG during tachycardia is helpful for defining the mechanism of PSVT. In patients with brief, self- terminating episodes, an event recorder is the most effective way to obtain ECG documentation.2 Patients with panic dis- order report symptoms similar to those of PSVT, and an ECG during palpita- tions aids in diagnosis.