Should a patient with tachycardia go to the ER?

Tachycardia Management: When to Seek Emergency Care

A patient with a heart rate of 135 beats per minute should go to the emergency room if they are experiencing symptoms of instability such as altered mental status, chest pain, heart failure, hypotension, or shock, as these indicate a potentially life-threatening situation requiring immediate intervention.

Initial Assessment of Tachycardia

When evaluating tachycardia (heart rate >100 beats per minute), several key factors determine the need for emergency care:

Stability Assessment

• Unstable signs requiring immediate ER care 1:

  • Acute altered mental status
  • Ischemic chest discomfort
  • Acute heart failure
  • Hypotension
  • Signs of shock

• Stable tachycardia may not require immediate ER evaluation if:

  • Heart rate <150 beats per minute
  • No symptoms of cardiovascular compromise
  • Clear physiologic cause (fever, dehydration, pain, anxiety)

Heart Rate Considerations

• Heart rate of 135 bpm falls in a critical zone:
  • According to the American Heart Association, a heart rate >150 bpm is more likely to cause symptoms due to the tachycardia itself 1
  • However, rates between 100-150 bpm can still indicate significant pathology, especially with underlying heart disease

Decision Algorithm for ER Evaluation

1. Go to ER immediately if:

   • Heart rate ≥135 bpm WITH any signs of instability
   • Sudden onset with palpitations, dizziness, or syncope
   • Known heart disease with new tachycardia
   • Wide QRS complex tachycardia (if known from previous ECG)
   • Irregular tachycardia with concerning symptoms

2. Consider ER evaluation if:

   • Heart rate ≥135 bpm persisting >30 minutes without clear cause
   • Associated symptoms like dyspnea or chest discomfort
   • History of cardiac disease
   • Age >65 years with new onset tachycardia
   • Recent medication changes that could affect heart rate

3. May not require immediate ER if:

   • Heart rate <150 bpm
   • Clear physiologic cause (fever, pain, anxiety)
   • No symptoms of cardiovascular compromise
   • Brief, self-terminating episodes
   • Young, healthy individual with no cardiac history

Types of Tachycardias Requiring Attention

Narrow-Complex Tachycardias

• Sinus tachycardia (usually physiologic response)
• Atrial fibrillation/flutter (may require anticoagulation)
• Supraventricular tachycardia (can cause significant symptoms)

Wide-Complex Tachycardias

• Always treat as ventricular tachycardia until proven otherwise 1, 2
• Require immediate medical attention due to risk of deterioration to ventricular fibrillation

Common Pitfalls in Tachycardia Management

• Misattribution to anxiety without adequate cardiac evaluation 2
• Focusing only on rate and missing paroxysmal arrhythmias 2
• Overlooking underlying causes like hyperthyroidism, anemia, or respiratory disorders 2
• Delaying cardioversion in unstable patients 1
• Using AV nodal blockers in pre-excited atrial fibrillation (can accelerate ventricular rate) 2

Potential Complications of Untreated Tachycardia

• Neurological complications including syncope (occurs in ~15% of SVT patients) 3
• Tachycardia-induced cardiomyopathy with prolonged elevated heart rates 4
• Thromboembolic events with certain arrhythmias like atrial fibrillation
• Progression to more serious arrhythmias or cardiac arrest

Conclusion

A heart rate of 135 bpm warrants careful evaluation. While not all cases require emergency care, the presence of concerning symptoms or risk factors should prompt immediate medical attention. The American Heart Association guidelines emphasize that when in doubt, especially with signs of instability, emergency evaluation is appropriate to rule out life-threatening conditions and initiate proper treatment 1.