What is the management for a 90-year-old female with second-degree atrioventricular (AV) block, significant bradycardia, and hypertension?

From the Guidelines

The management for a 90-year-old female with second-degree AV block, significant bradycardia, and hypertension should prioritize permanent pacemaker implantation, especially if symptomatic, to maintain an appropriate heart rate and prevent worsening bradycardia, as supported by 1.

Key Considerations

• The patient's significant bradycardia (HR 35-35) and hypertension (BP 189/67) require careful management to prevent complications such as cardiovascular collapse.
• Second-degree AV block can progress to complete heart block, emphasizing the need for prompt and effective treatment.
• The choice of antihypertensive medication is crucial, as some medications like beta-blockers can exacerbate bradycardia, whereas calcium channel blockers like amlodipine or angiotensin receptor blockers like losartan are generally safer options.

Temporary Measures

• Before pacemaker implantation, temporary measures such as atropine 0.5-1 mg IV for acute symptomatic bradycardia or isoproterenol infusion in emergency situations may be necessary, as indicated by 1 and 1.
• Monitoring in a setting with cardiac telemetry is essential until definitive treatment is established.

Long-term Management

• Permanent pacemaker implantation is recommended for symptomatic patients with second-degree AV block, as it improves survival and prevents complications, according to 1.
• The patient's clinical status and potentially reversible causes of bradycardia should be continuously evaluated, as suggested by 1.

From the FDA Drug Label

Esmolol hydrochloride is contraindicated in patients with: Severe sinus bradycardia: May precipitate or worsen bradycardia resulting in cardiogenic shock and cardiac arrest [see WARNINGS AND PRECAUTIONS (5. 2)]. Heart block greater than first degree: Second- or third-degree atrioventricular block may precipitate or worsen bradycardia resulting in cardiogenic shock and cardiac arrest [see WARNINGS AND PRECAUTIONS (5.2)].

The management for a 90-year-old female with second-degree atrioventricular (AV) block, significant bradycardia, and hypertension should avoid the use of esmolol due to its contraindications in patients with second- or third-degree atrioventricular block and severe sinus bradycardia.

• Key considerations:
  • Avoid esmolol due to contraindications 2
  • Consider alternative treatments for hypertension and bradycardia that do not worsen AV block. The patient's condition requires careful management to avoid worsening bradycardia and AV block. 2

From the Research

Management of Second-Degree AV Block

The management of a 90-year-old female with second-degree atrioventricular (AV) block, significant bradycardia, and hypertension involves several considerations.

• The patient's heart rate is 35-40 beats per minute, which is significantly lower than the normal range, indicating bradycardia.
• The blood pressure is 189/67 mmHg, which is elevated and may be related to the bradycardia 3.
• Second-degree AV block is a condition where there is a delay or blockage in the electrical conduction between the atria and ventricles, which can lead to bradycardia.

Treatment Options

Treatment options for second-degree AV block include:

• Atropine administration to increase heart rate, as seen in a case report where a patient with complete heart block responded to atropine 4.
• Pacemaker implantation, which may be considered if the patient has symptoms or hemodynamic compromise due to the AV block 5, 6.
• Management of hypertension, which may involve lifestyle modifications and medication to reduce blood pressure.

Considerations

Considerations in managing this patient include:

• The patient's age and potential comorbidities, which may affect treatment options and outcomes.
• The potential risks and benefits of atropine administration, including the risk of supraventricular or ventricular arrhythmias 7.
• The need for close monitoring and follow-up to assess the patient's response to treatment and adjust the management plan as needed.