What is the least appropriate management option for a 65-year-old woman with atrial fibrillation (AF) and a rapid ventricular rate, stable blood pressure, and no signs of hypovolemia or dehydration, who is being treated for an infective exacerbation of asthma?

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Management of Atrial Fibrillation with Rapid Ventricular Response in a Patient with Asthma Exacerbation

IV Metoprolol would be the LEAST appropriate management option for this patient's tachycardia due to her asthma exacerbation, as beta-blockers can worsen bronchospasm and potentially exacerbate her respiratory condition. 1

Patient Assessment

This 65-year-old woman presents with:

  • Atrial fibrillation with rapid ventricular response (HR 140/min)
  • Stable blood pressure (105/75 mmHg)
  • Fever (39.4°C)
  • Infective exacerbation of asthma
  • History of hypertension and angina
  • Current medications: perindopril, verapamil, and asthma inhalers

Analysis of Management Options

Option C: IV Metoprolol (LEAST APPROPRIATE)

  • Beta-blockers are contraindicated in acute asthma exacerbations as they can cause bronchospasm
  • The patient is already experiencing an infective exacerbation of asthma, and metoprolol could worsen her respiratory status significantly
  • While beta-blockers are typically first-line for AF rate control, they must be used cautiously or avoided in patients with active bronchospasm 1

Option A: Oral Paracetamol (APPROPRIATE)

  • Appropriate for treating the patient's fever (39.4°C)
  • Fever increases metabolic demand and can worsen tachycardia
  • Reducing fever may help decrease heart rate indirectly
  • No contraindications in this patient

Option B: IV Fluid Bolus (APPROPRIATE)

  • Appropriate for a patient with potential dehydration from fever and tachypnea
  • Can improve hemodynamic stability
  • May help reduce heart rate by improving volume status
  • No evidence of fluid overload in this patient

Option D: IV Magnesium Sulfate (APPROPRIATE)

  • Beneficial for both asthma exacerbation and rate control in AF
  • Has bronchodilatory effects that would benefit the patient's asthma
  • Can help with rate control in AF without the bronchospastic risks of beta-blockers
  • No contraindications in this patient with normal blood pressure

Recommended Management Approach

  1. Address fever first: Administer oral paracetamol to reduce fever and associated metabolic demand

  2. Support circulation: Provide IV fluid bolus to address potential dehydration from fever and increased respiratory rate

  3. Rate control with safe agents:

    • IV magnesium sulfate (10 mmol) - beneficial for both asthma and AF rate control
    • Consider non-dihydropyridine calcium channel blockers (patient is already on verapamil)
    • Avoid beta-blockers during active asthma exacerbation

  4. Treat underlying infection:

    • Appropriate antibiotics for the infective exacerbation
    • Continue asthma medications and optimize bronchodilator therapy

Important Considerations

  • The European Society of Cardiology recommends avoiding beta-blockers in patients with active bronchospasm 1
  • Non-dihydropyridine calcium channel blockers (like the patient's home verapamil) are safer alternatives for rate control in patients with asthma
  • Magnesium sulfate serves dual purposes in this patient - bronchodilation for asthma and rate control for AF
  • Beta-blockers could be reconsidered once the asthma exacerbation has resolved

Pitfalls to Avoid

  • Using beta-blockers in acute asthma exacerbations can precipitate severe bronchospasm
  • Failing to treat the fever, which contributes to tachycardia and increased metabolic demand
  • Overlooking the importance of fluid resuscitation in patients with fever and potential dehydration
  • Focusing solely on rate control without addressing the underlying infection and asthma exacerbation

In conclusion, IV metoprolol is the least appropriate option due to the significant risk of worsening the patient's asthma exacerbation, while the other options (paracetamol, IV fluids, and magnesium sulfate) would all be appropriate components of this patient's management.

References

1
Guideline

Atrial Fibrillation with Rapid Ventricular Response

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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