What is the next step in managing a 65-year-old male presenting to the Emergency Department (ED) with heart palpitations, tachycardia (heart rate 130), and an electrocardiogram (EKG) showing irregular rhythm, with no previous medical history?

From the Guidelines

The next step in managing this 65-year-old male with palpitations, tachycardia (HR 130), and irregular rhythm on EKG is to initiate rate control with a beta-blocker or calcium channel blocker, while simultaneously assessing the need for anticoagulation using the CHA₂DS₂-VASc score, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1.

Initial Assessment and Management

To stabilize the patient and treat what is likely atrial fibrillation, the following steps should be taken:

• Obtain a 12-lead EKG to confirm atrial fibrillation and assess for any additional abnormalities.
• Check vital signs including blood pressure and oxygen saturation, and establish IV access.
• If the patient is hemodynamically stable, rate control should be initiated with either a beta-blocker (such as metoprolol 5mg IV, which can be repeated up to 3 doses) or a calcium channel blocker (diltiazem 0.25 mg/kg IV over 2 minutes), as suggested by the 2024 ESC guidelines 1.

Laboratory Tests and Imaging

Basic laboratory tests should be ordered including:

• Complete blood count
• Comprehensive metabolic panel
• Thyroid function tests
• Cardiac enzymes to identify potential triggers or complications. A chest X-ray and echocardiogram should be performed to evaluate for structural heart disease, as recommended by the 2024 ESC guidelines for the initial evaluation of patients with atrial fibrillation 1.

Anticoagulation Assessment

Anticoagulation assessment using the CHA₂DS₂-VASc score is essential, as this 65-year-old male already has at least 1 point for age and would likely benefit from anticoagulation therapy to prevent stroke, in accordance with the 2024 ESC guidelines 1.

Cardioversion Consideration

If this is his first episode of atrial fibrillation and it started within 48 hours, cardioversion could be considered after initial stabilization, taking into account the patient's individual risk of thromboembolism and the need for anticoagulation, as recommended by the 2024 ESC guidelines 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Dosing and Administration in Adults Therapy with Sotalol AF must be initiated (and, if necessary, titrated) in a setting that provides continuous electrocardiographic (ECG) monitoring and in the presence of personnel trained in the management of serious ventricular arrhythmias The baseline QT interval must be ≤450 msec in order for a patient to be started on Sotalol AF therapy. Initiation of Sotalol AF Therapy Step 1. Electrocardiographic assessment: Prior to administration of the first dose, the QT interval must be determined using an average of 5 beats If the baseline QT is greater than 450 msec (JT ≥330 msec if QRS over 100 msec), Sotalol AF is contraindicated.

The next step in managing a 65-year-old male presenting to the Emergency Department (ED) with heart palpitations, tachycardia (heart rate 130), and an electrocardiogram (EKG) showing irregular rhythm, with no previous medical history, is to:

• Perform an electrocardiographic assessment to determine the baseline QT interval
• Check if the QT interval is ≤450 msec to determine eligibility for Sotalol AF therapy
• If the QT interval is >450 msec, Sotalol AF is contraindicated
• Consider alternative treatments, such as metoprolol, which may be initiated in a coronary care or similar unit immediately after the patient’s hemodynamic condition has stabilized 2
• Start with a low initial dose in elderly patients, given their greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy 2

From the Research

Next Steps in Managing Atrial Fibrillation

The patient presents with heart palpitations, tachycardia (heart rate 130), and an electrocardiogram (EKG) showing irregular rhythm. Given the symptoms, the next step would be to achieve rate control.

• The goal of rate control is to slow the heart rate to a normal range and prevent symptoms and complications associated with atrial fibrillation.
• Studies have compared the effectiveness of different medications, including metoprolol and diltiazem, in achieving rate control in patients with atrial fibrillation 3, 4, 5.

Medication Options

• Metoprolol and diltiazem are both commonly used to achieve rate control in atrial fibrillation.
• A study published in 2019 found that intravenous push (IVP) diltiazem achieved similar rate control with no increase in adverse events when compared to IVP metoprolol in patients with heart failure with reduced ejection fraction (HFrEF) 3.
• Another study published in 2022 found that IVP diltiazem reduced heart rate more quickly and reduced heart rate by 20% or greater more frequently than IVP metoprolol in patients with atrial fibrillation and heart failure, with no safety outcome differences 4.
• A 2021 study found that the primary outcome, rate control at two hours after the last bolus dose of metoprolol or diltiazem, was similar between the two groups, but diltiazem had a significantly higher occurrence of hypotension 5.

Considerations

• The choice of medication should be based on the individual patient's characteristics, including their medical history, symptoms, and other health conditions.
• Beta-blockers, such as metoprolol, are often considered first-line treatment for rate control in atrial fibrillation, but calcium channel blockers, such as diltiazem, may be used as an alternative or in combination with beta-blockers 6.
• The patient's heart rate and rhythm should be closely monitored after administration of the medication to assess the effectiveness of treatment and adjust the dose or medication as needed.