What medication can be given to a 69-year-old male patient with supraventricular tachycardia (SVT) and hypertension (HTN)?

Management of Supraventricular Tachycardia in a 69-Year-Old Male with Hypertension

Beta blockers are the first-line medication of choice for this 69-year-old male patient with SVT and hypertension, with metoprolol being the preferred agent due to its efficacy in controlling both conditions. 1

Assessment of Current Condition

This patient presents with:

• Frequent SVT episodes (362 runs) documented on cardiac monitoring
• Longest SVT episode lasting 16.6 seconds at 118 bpm
• Hypertension
• Right bundle branch block (RBBB)
• Normal left ventricular ejection fraction (LVEF 60%)
• Moderate left atrial dilation
• Normal myocardial perfusion

Treatment Algorithm

Acute Management (if needed)

1. First-line: Vagal maneuvers 1
2. Second-line: Adenosine (if hemodynamically stable) 1
3. Third-line: IV beta blockers or calcium channel blockers (if hemodynamically stable) 1
4. For hemodynamic instability: Synchronized cardioversion 1

Long-term Management

1. First-line medication: Oral beta blockers (metoprolol preferred) 1

   • Effective for both SVT and hypertension
   • Particularly beneficial in this patient with moderate left atrial dilation
   • Dosing: Start with metoprolol 25-50 mg twice daily, titrate as needed

2. Alternative options (if beta blockers contraindicated or ineffective):

   • Non-dihydropyridine calcium channel blockers (diltiazem or verapamil) 1
   • Consider adding an ACE inhibitor or ARB for optimal HTN management, especially with left atrial dilation 1

3. Consider EP study with ablation if:

   • Symptoms worsen despite medical therapy
   • Patient prefers definitive treatment
   • Drug therapy is ineffective or poorly tolerated 1

Rationale for Beta Blocker Selection

Beta blockers are strongly recommended for this patient because:

1. Dual benefit: They effectively treat both SVT and hypertension simultaneously 1

2. Evidence-based: Guidelines from the European Heart Rhythm Association, American College of Cardiology, American Heart Association, and Heart Rhythm Society all recommend beta blockers for SVT management 1

3. Specific benefits for this patient:

   • Can reduce the frequency and duration of SVT episodes 1
   • Help control heart rate during SVT episodes 1
   • May reduce the risk of SVT progression to more serious arrhythmias 1
   • Beneficial for hypertension management 1

4. Safety profile: Appropriate for this patient with normal LVEF (57-60%) 1

Important Considerations and Monitoring

• Monitor for bradycardia: Especially important with RBBB
• Evaluate efficacy: Follow-up with repeat Holter monitoring to assess SVT burden reduction
• Blood pressure monitoring: Ensure adequate HTN control
• Electrolyte balance: Maintain normal potassium and magnesium levels
• Avoid abrupt discontinuation: If medication changes are needed, taper slowly to prevent rebound tachyarrhythmias 2

Potential Pitfalls to Avoid

• Avoid flecainide without careful evaluation: While effective for SVT, it requires caution in patients with structural heart disease 3
• Avoid digoxin: Less effective for SVT control and has more potential for adverse effects 1
• Avoid dihydropyridine calcium channel blockers alone: They control HTN but not SVT 1
• Don't delay treatment: Untreated SVT can lead to tachycardia-induced cardiomyopathy over time 1

Beta blockers represent the optimal first-line choice for this patient, addressing both the SVT and hypertension while having a favorable safety profile given his cardiac status.