How to manage a 78-year-old male with arrhythmias, mild TR, and pulm HTN on Metoprolol Tartrate (metoprolol) and Eliquis (apixaban)?

Management of Arrhythmias in a 78-Year-Old Male with Mild Pulmonary Hypertension

Beta-blocker therapy with metoprolol should be continued and potentially uptitrated to better control the patient's arrhythmias (sinus tachycardia, bradycardia, NSVT, PSVT), while maintaining anticoagulation with Eliquis for stroke prevention. 1

Assessment of Current Cardiac Status

The patient presents with:

• Multiple arrhythmias: sinus tachycardia, bradycardia, NSVT, PSVT (52-213 bpm, avg 83)
• Preserved ejection fraction (EF 60-65%)
• Mild tricuspid regurgitation
• Mild pulmonary hypertension (RVSP 39 mmHg)
• Possible inferior wall perfusion defect (likely diaphragmatic artifact)

Management Strategy

1. Optimize Beta-Blocker Therapy

• Current dose: Metoprolol tartrate 25 mg twice daily
• Recommendation: Consider uptitrating metoprolol to better control heart rate variability
  • Target initial resting heart rate <110 bpm 2
  • Metoprolol is appropriate for this patient as:
    • It effectively controls both supraventricular and ventricular arrhythmias 1
    • It's suitable for elderly patients with preserved EF 1
    • It can reduce the frequency of SVT episodes 1

2. Maintain Anticoagulation

• Current therapy: Eliquis (apixaban)
• Recommendation: Continue Eliquis for stroke prevention
  • This patient has at least 1 point on CHA₂DS₂-VASc score (age) and likely more given his cardiac profile 1
  • NOACs like apixaban are preferred over vitamin K antagonists 2
  • Anticoagulation should be maintained regardless of rate or rhythm control strategy 2

3. Additional Diagnostic Evaluation

• Consider 30-day event monitoring to better characterize arrhythmia burden and correlation with symptoms 1
• Evaluate for potential causes of arrhythmias:
  • Check electrolytes, particularly potassium and magnesium levels 1
  • Assess thyroid function (hyperthyroidism can exacerbate arrhythmias) 3
  • Consider sleep study to evaluate for sleep apnea (common in patients with hypertension and arrhythmias) 1

Specific Considerations for This Patient

Beta-Blocker Dosing in Elderly

• Start with lower doses and titrate more gradually due to altered pharmacokinetics in elderly patients 3
• Monitor for bradycardia, as metoprolol can cause sinus pauses and heart blocks 3
• Do not abruptly discontinue metoprolol due to risk of exacerbating angina and ventricular arrhythmias 3

Management of Multiple Arrhythmia Types

1. For SVT/PSVT:

   • Beta-blockers are first-line therapy for rate control 1, 2
   • If symptoms persist despite beta-blocker therapy, consider referral for electrophysiology study and possible ablation 1

2. For NSVT:

   • Beta-blockers are appropriate first-line therapy, especially with preserved EF 1
   • Monitor for progression of ventricular arrhythmias 1

3. For bradycardia:

   • If bradycardia worsens with beta-blocker therapy, consider dose reduction 3
   • Evaluate for underlying conduction system disease

Heart Rate Control vs. Rhythm Control

• For this 78-year-old patient with multiple arrhythmias and preserved EF, rate control with beta-blockers is the preferred initial strategy 1, 2
• If rate control fails to improve symptoms, consider rhythm control strategies or combination therapy 1

Monitoring and Follow-up

• Schedule follow-up within 2-4 weeks to assess response to therapy
• Monitor for:
  • Heart rate control (target <110 bpm at rest) 2
  • Symptoms of bradycardia or heart block
  • Signs of heart failure (despite preserved EF)
  • Bleeding complications from anticoagulation

Potential Pitfalls and Caveats

• Beta-blockers may mask symptoms of hypoglycemia in diabetic patients 3
• Metoprolol may mask signs of hyperthyroidism (tachycardia) 3
• Elderly patients may be more sensitive to beta-blockers; monitor for excessive bradycardia 1
• If the patient has underlying bronchospastic disease, use metoprolol cautiously and consider smaller, more frequent dosing 3

If the patient's arrhythmias remain poorly controlled despite optimized beta-blocker therapy, consider adding a non-dihydropyridine calcium channel blocker or amiodarone, or referral for electrophysiology evaluation and possible ablation 1, 2.