How should an asymptomatic 89-year-old male with complete heart block, recent pulmonary embolism on Eliquis (apixaban), and hypertension be managed?

Management of Asymptomatic Complete Heart Block in an Elderly Patient with Recent PE

This 89-year-old male with complete heart block, recent PE on Eliquis, and hypertension should be admitted for continuous cardiac monitoring and permanent pacemaker placement tomorrow as recommended by the EP consultant.

Clinical Assessment and Risk Stratification

The patient presents with:

• Complete (3rd degree) heart block
• Heart rate 30-35 bpm
• Blood pressure 160/80 mmHg
• Currently asymptomatic despite profound bradycardia
• History of CAD without prior MI
• Unprovoked PE 2 months ago, currently on Eliquis (apixaban)
• Recent 3-day history of SOB and weakness

Despite the patient being currently asymptomatic, complete heart block represents a high-risk condition that warrants hospital admission for several reasons:

1. Risk of hemodynamic deterioration: Complete heart block can rapidly progress to hemodynamic instability, especially in elderly patients with underlying cardiovascular disease.

2. Need for definitive management: The EP consultant has already recommended pacemaker placement tomorrow, indicating the need for inpatient management.

3. Anticoagulation considerations: The patient's recent PE and current Eliquis therapy require careful perioperative management for the pacemaker procedure.

Immediate Management

• Continuous cardiac monitoring: Essential for detecting any deterioration in heart rate or development of symptoms
• Transcutaneous pacing pads: Already appropriately placed, should remain in position
• Standby external pacing: Equipment should be immediately available if the patient develops symptoms or hemodynamic instability
• Blood pressure management: Monitor closely as the patient is hypertensive (160/80 mmHg) despite profound bradycardia

Anticoagulation Management

For patients on Eliquis requiring pacemaker placement:

• Eliquis should be discontinued at least 24-48 hours prior to the procedure 1
• Bridging anticoagulation is generally not required during this short interruption 1
• Eliquis should be restarted after the procedure once adequate hemostasis is established 1

Admission Plan

1. Admission location: Telemetry unit with continuous cardiac monitoring

2. Consultation services: Cardiology and EP service (already consulted)

3. Medication management:

   • Continue current medications except for planned perioperative interruption of Eliquis
   • Have atropine and external pacing equipment readily available

4. Monitoring parameters:

   • Continuous cardiac monitoring
   • Vital signs including blood pressure every 4 hours
   • Assess for symptoms of decreased cardiac output (dizziness, syncope, altered mental status)
   • Monitor for signs of heart failure or pulmonary edema

5. Diagnostic workup:

   • 12-lead ECG to confirm complete heart block
   • Basic laboratory studies including electrolytes, renal function, and cardiac biomarkers
   • Consider echocardiogram to assess cardiac function and rule out structural abnormalities

Post-Pacemaker Considerations

After pacemaker placement, the patient will require:

• Chest X-ray to confirm lead placement and rule out pneumothorax
• Device interrogation to ensure proper functioning
• Resumption of Eliquis once hemostasis is adequate
• Routine clinical evaluation 3-6 months after discharge to assess for PE resolution 2, 3

Potential Pitfalls and Caveats

1. Don't delay pacemaker placement: Despite being currently asymptomatic, complete heart block in an elderly patient with cardiovascular disease requires definitive management with permanent pacing.

2. Avoid temporary transvenous pacing if possible: If the patient remains hemodynamically stable, it's preferable to proceed directly to permanent pacemaker placement rather than inserting a temporary transvenous pacemaker, which carries additional risks.

3. Careful anticoagulation management: Balancing the risks of thromboembolism versus bleeding requires careful timing of Eliquis interruption and resumption around the pacemaker procedure.

4. Monitor for PE-related complications: Given the recent PE history, the patient should be monitored for signs of pulmonary hypertension or right heart strain, which could complicate management.