Decompensated heart failure with right-sided congestion and rapid AF — case discussion

This scenario is fictional and invented for teaching; it does not describe a real person.

Objectives

1. Place the presentation in the 2026 ESC categories and assess congestion and perfusion. ^[1]
2. Interpret the natriuretic peptide and decide the level of care. ^[1]
3. Prescribe and escalate decongestion with ESC 2026 doses and response targets. ^{[1] [5] [6]}
4. Manage AF with rapid rates, thromboprophylaxis, foundational therapy and the early follow-up phase. ^{[1] [2] [22]}

Candidate brief

You are the cardiology consultant on call. Take the examiner through assessment and management from arrival to the first weeks after discharge, giving the ESC 2026 class and level where one exists. ^[1]

Expected actions

• Recognise signs of right-sided congestion (peripheral oedema, abdominal distension, hepatomegaly, jugular vein distension, hepatojugular reflux); her peripheries are warm, and no other sign of hypoperfusion is reported in the presentation. With known HFrEF, this may represent decompensated left-sided HF which, in advanced stages, can lead to RV dysfunction and decompensated right-sided HF (combined left- and right-sided HF); the categories can overlap. If right-sided HF is isolated, pulmonary embolism and acute MI involving the right ventricle need to be excluded.^[1]
• In decompensated right-sided HF, RV function and its effect on the kidney and liver usually determine the clinical trajectory, so kidney and hepatic function need close monitoring.^[1]
• NT-proBNP above 5000 pg/mL indicates very high risk; admission is generally recommended.^[1]
• SpO₂ 93% is above the ESC oxygen threshold: oxygen is recommended for SpO₂ below 90% or PaO₂ below 60 mmHg (Class I, Level C), and indiscriminate oxygen in non-hypoxaemic patients may be harmful. Non-invasive ventilation should be used with caution in patients with reduced preload reserve and hypotension, such as decompensated right-sided HF.^[1]
• She has fluid overload (oedema to the thighs), so an i.v. loop diuretic is recommended (Class I, Level A). She is on a loop diuretic, so an i.v. dose of twice the usual oral dose, furosemide 160 mg i.v., should be considered.^[1]
• Check response: urinary sodium ≥70 mEq/L at 2 h or urine ≥100 mL/h over the first 6 h. If insufficient, the i.v. dose can be doubled and/or a non-loop diuretic added; as she is on loop diuretics, adding short-term acetazolamide 500 mg i.v. once daily or oral hydrochlorothiazide by eGFR should be considered (Class IIa, Level B1). Consider further escalation on day 2 if 24-hour diuresis is below 3 L with ongoing congestion.^{[1] [6]}
• Judge any creatinine rise against the diuretic response: small, transient rises are not associated with a poor outcome if decongestion is achieved.^[1]
• AF with rapid rates: BP 104/68 mmHg with warm peripheries and no reported sign of hypoperfusion; reassess her haemodynamic status. Urgent cardioversion is recommended in DHF with rapid ventricular rates and haemodynamic instability to restore sinus rhythm (Class I, Level C). I.v. amiodarone or digoxin may be considered for acute rate control in unstable HFrEF with AF (Class IIb, Level C). In HFrEF, avoid propafenone, flecainide and dronedarone (poorer outcomes).^[1] If she is judged stable, beta-blockers are recommended as first-line short- and long-term rate control in stable HFrEF with AF (Class I, Level C). In stable HFrEF with AF, digoxin should be considered if the rate stays high despite beta-blockers, or if they are contraindicated or not tolerated (Class IIa, Level C). Assess thromboembolic risk with the CHA₂DS₂-VA score: oral anticoagulation is recommended at elevated risk (Class I, Level A), with DOACs in preference to VKAs in HF (Class I, Level B1) except in moderate or severe mitral stenosis or mechanical prosthetic valves.^[1]
• If she already takes foundational medical therapy, continue it; discontinuation is not recommended unless there are clear signs of hypoperfusion or specific clinical indications.^[1]
• Thromboprophylaxis: ESC 2026 makes no definitive recommendation but considers it generally indicated with immobilisation or other risk factors. AHA/ACC/HFSA 2022: in patients admitted specifically for decompensated HF with creatinine clearance above 30 mL/min, randomised trials suggest that enoxaparin 40 mg subcutaneously once daily, unfractionated heparin 5000 units subcutaneously every 8 or 12 hours, or rivaroxaban 10 mg once daily radiographically reduce demonstrable venous thrombosis.^{[1] [2]}
• Start an SGLT2 inhibitor in hospital after stabilisation (Class I, Level B1).^[1]
• Before discharge, carefully evaluate her to exclude persistent signs of congestion (Class I, Level C). Plan rapid FMT initiation and uptitration before discharge and during frequent follow-up visits in the first 6 weeks (Class I, Level B2), as in STRONG-HF.^{[1] [22]}

Marking

Pass:

• names the 2026 ESC category (recognising overlap between left- and right-sided HF) and separates congestion from hypoperfusion.
• interprets NT-proBNP above 5000 pg/mL as very high risk.
• does not give routine oxygen at SpO₂ 93% without hypoxaemia, and is cautious with non-invasive ventilation in right-sided HF.
• considers i.v. furosemide at twice the usual oral dose for her fluid overload and defines the 2 h and 6 h response checks.
• escalates with a non-loop diuretic at the correct dose.
• recognises that urgent cardioversion (I, C) and i.v. amiodarone or digoxin for acute rate control (IIb, C) are the recommendations for haemodynamic instability, uses beta-blocker-based rate control (digoxin as second line) if she is stable, addresses anticoagulation by CHA₂DS₂-VA, and avoids propafenone, flecainide and dronedarone.
• starts an SGLT2 inhibitor in hospital after initial stabilisation and plans STRONG-HF-style follow-up.

Fail:

• gives routine high-flow oxygen without hypoxaemia.
• ignores her chronic loop diuretic use when choosing the i.v. dose, and never checks the response.
• stops diuretics for a small creatinine rise while still congested.
• uses flecainide or dronedarone for AF in HFrEF.
• stops existing foundational therapy without hypoperfusion or a specific clinical indication.
• discharges without checking for residual congestion or arranging early follow-up.