From the Guidelines
In the setting of infection, rate control is not typically used for sinus tachycardia because the elevated heart rate is an appropriate physiologic response to infection. This approach is supported by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia, which states that physiological sinus tachycardia may result from pathological causes, including infection with fever, dehydration, anemia, heart failure, and hyperthyroidism, and that tachycardia is expected to resolve with correction of the underlying cause 1.
Some key points to consider in this context include:
- The tachycardia is often a response to fever, increased metabolic demands, or relative hypovolemia, and treating the underlying infection with appropriate antibiotics, providing adequate hydration, and managing fever with antipyretics like acetaminophen is the preferred approach.
- Rate control medications, such as beta-blockers (like metoprolol, atenolol) or calcium channel blockers (like diltiazem, verapamil), may cause unwanted hypotension in patients who may already be hemodynamically compromised due to sepsis or systemic inflammatory response.
- Additionally, some rate-controlling agents like beta-blockers can impair the body's ability to mount an appropriate immune response 1.
- The heart rate will typically normalize once the infection resolves, making specific rate control unnecessary and potentially harmful in this context.
Overall, the focus should be on treating the underlying infection and managing its symptoms, rather than attempting to control the heart rate with medications.
From the Research
Rate Control in Sinus Tachycardia
- Rate control is not typically used for sinus tachycardia (sinus tach) in the setting of an infection because the primary goal is to address the underlying cause of the tachycardia, such as fever, hypovolemia, or anemia 2.
- In the context of sepsis, sinus tachycardia is often a compensatory response to maintain cardiac output, and controlling the heart rate may not be beneficial until the underlying condition is stabilized 2.
- The use of beta-blockers, such as ultrashort-acting β1-blockers, may be considered in septic patients with non-compensatory tachycardia, but only after completing initial resuscitation 2.
Treatment of Sinus Tachycardia
- Calcium channel blockers, such as diltiazem, can be effective in treating sinus tachycardia in critically ill patients, especially those with contraindications to beta-blockers or in whom beta-blockers are ineffective 3.
- Ivabradine, a new agent that inhibits sinus node I(f) current, has been shown to be effective in reducing heart rate and relieving symptoms in patients with inappropriate sinus tachycardia 4.
Considerations for Rate Control
- The decision to use rate control should be based on individual patient characteristics, such as the presence of underlying heart disease, haemodynamic impairment, and the clinical context 5, 6.
- Rate control should be adapted to patients' individual characteristics to grant control during daily activities, including exercise 5.