Agent Network

Stable or unstable?

Unstable = act now Any of: hypotension/shock · ongoing ischemia · acute pulmonary edema/hypoxia · altered mentation.

So what do you use?

Preferred IV Digoxin Doesn't drop BP; useful when decompensated or hypotensive. Slower onset (hours) — a good adjunct. Watch for: narrow therapeutic window — nausea/vomiting, visual color changes, confusion, bradyarrhythmias. Risk ↑ with renal impairment, hypokalemia, hypomagnesemia, and amiodarone (↑ digoxin level — cut the dose). Effective, but caution IV Amiodarone Rate control when decompensated.

How low do you actually need to go?

RACE II — lenient rate control (resting HR <110) was non-inferior to strict control (<80) for cardiovascular outcomes in stable patients. Van Gelder IC, et al. N Engl J Med 2010 · PMID 20231232 ▸Start with a lenient target — you don't have to chase <80. ▸Tighten only if the patient stays symptomatic or the HF isn't improving. Evidence · Rate vs Rhythm

Why did the diltiazem error happen at all?

The safest fix isn't remembering harder. A well-built order set or CDS check can flag "EF < 40% — avoid non-DHP CCB" at the moment of ordering, so the system catches it even on a busy night. ▸Good decision support turns a memorized pearl into a guardrail. ▸Bad alerts get ignored — the design matters as much as the rule. References