What is the next step in managing a 64-year-old female patient with hypertension, borderline lipidemia, palpitations, tachycardia, and decreased ejection fraction?

Management of Tachycardia and Reduced Ejection Fraction in a 64-Year-Old Female

The next step in managing this patient should be to initiate beta-blocker therapy, specifically metoprolol, to address both the tachycardia and reduced ejection fraction. 1

Assessment of Current Clinical Picture

This 64-year-old female patient presents with:

• Hypertension and borderline lipidemia
• Palpitations
• Tachycardia (average heart rate of 95 beats per minute)
• Decreased ejection fraction (45-50%)
• Normal stress test
• No significant rhythm abnormalities on Holter monitoring

Management Algorithm

Step 1: Initiate Beta-Blocker Therapy

• Start metoprolol 25-50mg twice daily as first-line therapy 1, 2
• Beta-blockers are specifically recommended for:
  • Patients with reduced ejection fraction (EF 45-50%) 1
  • Management of tachycardia and palpitations 2
  • Patients with hypertension and heart failure 1

Step 2: Consider Additional Medications

• After establishing beta-blocker therapy, add an ACE inhibitor or ARB 1
  • These agents provide additional benefit in reducing sudden cardiac death risk independent of blood pressure reduction 1
  • They are recommended for patients with decreased ejection fraction 1

Step 3: Diagnostic Evaluation

• Obtain a comprehensive cardiac evaluation:
  • Transthoracic echocardiography to further assess structural heart disease 1
  • Evaluate for potential causes of tachycardia:
    • Investigate excessive intake of alcohol, caffeine, or other stimulants 1
    • Assess for chronic exposure to high-stress conditions 1
    • Check electrolyte abnormalities, particularly potassium levels 1

Rationale for Beta-Blocker Therapy

Beta-blockers are the cornerstone of treatment in this case for several reasons:

1. They effectively reduce heart rate and alleviate palpitations 2
2. They improve outcomes in patients with reduced ejection fraction 1
3. They provide mortality benefit in patients with hypertension and cardiac dysfunction 1

The European Heart Rhythm Association and ESC Council on Hypertension specifically recommend beta-blockers for patients with hypertension who have tachycardia and reduced ejection fraction 1. While the patient's ejection fraction is borderline (45-50%), this still represents mild systolic dysfunction that warrants treatment.

Important Considerations

• Avoid Class IC antiarrhythmic agents (e.g., flecainide) as they are contraindicated in patients with structural heart disease or LV dysfunction 1
• Monitor for bradycardia during beta-blocker initiation, especially in elderly patients 3
• Start at a low dose and titrate gradually based on heart rate response and symptoms 3
• Consider amiodarone only if the patient continues to have symptomatic ventricular arrhythmias despite optimal treatment with beta-blockers and ACE inhibitors/ARBs 1

Long-Term Management

If the patient's symptoms persist despite optimal medical therapy:

• Consider 24-hour Holter monitoring to further characterize any arrhythmias 1
• Evaluate for potential need for cardiac resynchronization therapy if QRS duration is prolonged 1
• Consider referral to an electrophysiologist if symptoms persist despite medical therapy 1

The goal should be to achieve a resting heart rate between 60-80 beats per minute 2, which should help alleviate palpitations while improving cardiac function through reduced myocardial oxygen demand and improved diastolic filling time.