From the Guidelines
The patient should be given intravenous amiodarone to control the atrial flutter, alongside continuation of bisoprolol 2.5mg twice daily, and anticoagulation with dalteparin should be continued due to the high risk of thromboembolism associated with atrial flutter, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.
Atrial Flutter Management
The management of atrial flutter in this patient requires consideration of the underlying conditions, including the chest infection and nephrotic syndrome. According to the 2015 ACC/AHA/HRS guideline, antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF 1. The guideline suggests that the risk of stroke associated with atrial flutter is similar to that in patients with AF, and anticoagulation has been shown to prevent stroke when administered during the weeks immediately before and after cardioversion 1.
Rate Control and Anticoagulation
The patient is already on bisoprolol 2.5mg twice daily, which should be continued to control the heart rate. However, to convert the atrial flutter to sinus rhythm, intravenous amiodarone can be considered, as it is a reasonable option for patients with symptomatic, recurrent atrial flutter, particularly in those with underlying heart disease or comorbidities 1. The dose of amiodarone should be adjusted according to the patient's renal function and monitored closely for potential toxicities.
Nephrotic Syndrome and Chest Infection Management
The management of nephrotic syndrome and chest infection should be coordinated with the cardiology team to ensure that the treatments do not interact negatively with the atrial flutter management. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers can be used to reduce proteinuria, and diuretics can be used to manage edema. Antibiotic therapy should be tailored to the likely pathogens causing the chest infection.
Key Considerations
- The patient's renal function should be monitored closely, as the use of diuretics and potential nephrotoxicity of certain antibiotics may worsen renal function.
- The patient's electrolyte balance should be monitored, as diuretics may cause electrolyte imbalances.
- The patient's fluid status should be monitored, as the nephrotic state increases thrombotic risk, potentially complicating anticoagulation decisions.
Treatment Summary
- Intravenous amiodarone to control atrial flutter
- Continuation of bisoprolol 2.5mg twice daily for rate control
- Anticoagulation with dalteparin to prevent thromboembolism
- Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers to reduce proteinuria
- Diuretics to manage edema
- Antibiotic therapy tailored to the likely pathogens causing the chest infection
- Close monitoring of renal function, electrolytes, and fluid status.
From the FDA Drug Label
PRECAUTIONS Digoxin is primarily excreted by the kidneys; therefore, patients with impaired renal function require smaller than usual maintenance doses of digoxin Use in Patients with Impaired Renal Function:DOSAGE AND ADMINISTRATION Although beta-adrenergic blockers or calcium channel blockers and digoxin may be useful in combination to control atrial fibrillation, their additive effects on AV node conduction can result in advanced or complete heart block
The patient has atrial flutter, nephrotic syndrome, and is on bisoprolol. Considering the patient's renal impairment due to nephrotic syndrome, digoxin should be used with caution. The patient is already on a beta-blocker (bisoprolol), and adding digoxin may increase the risk of advanced or complete heart block.
- The patient's ECG shows flutter, rate 143, indicating a need for rate control.
- Bisoprolol is already being used, but the dose may need to be adjusted or an additional medication considered to achieve adequate rate control.
- Given the patient's complex medical condition, including nephrotic syndrome and chest infection, careful consideration of the patient's renal function and electrolyte balance is necessary before initiating or adjusting any medication, including digoxin 2.
- It is essential to monitor the patient's serum electrolytes and renal function periodically to avoid digitalis toxicity 2.
From the Research
Management Approach
The patient has atrial flutter with a rate of 143, and is already on bisoprolol 2.5mg BD. Considering the patient's condition, the management approach should focus on controlling the ventricular rate.
- According to 3, atrioventricular node blocking agents, including beta-adrenergic blockers, are usually effective in controlling ventricular rate in atrial fibrillation and flutter.
- The patient is already on bisoprolol, which is a beta-blocker, so the current medication can be continued or adjusted as needed.
Rate Control vs Rhythm Control
- A study 4 found that attempts at rate and rhythm control in patients with complex atrial fibrillation or flutter are associated with a higher adverse event rate, and the success rates of these attempts appear low.
- However, another study 5 compared digoxin and bisoprolol for heart rate control in atrial fibrillation and found no significant difference in quality of life at 6 months.
Medication Options
- Beta-blockers, such as bisoprolol, are preferred for rate control in atrial fibrillation and flutter, especially in patients with myocardial ischemia or myocardial infarction 3.
- Digoxin can also be used for rate control, but its effectiveness compared to beta-blockers is unclear 6.
- A systematic review 7 found that bisoprolol is effective for the treatment of supraventricular arrhythmias, including atrial fibrillation, and can be used for rate control.
Recommendations
- Continue or adjust the patient's current bisoprolol medication as needed to control the ventricular rate.
- Monitor the patient's condition and adjust the treatment plan accordingly.
- Consider consulting with a cardiologist or other specialist for further guidance on managing the patient's atrial flutter and underlying medical conditions.