Is it okay to send a patient home with tachycardia and refer to cardiology if other symptoms improve?

Management of Patients with Heart Rate of 137 and Cardiology Referral

Sending a patient home with a heart rate of 137 is not recommended, even with a cardiology referral, as this level of tachycardia can lead to tachycardia-induced cardiomyopathy and requires immediate intervention before discharge.

Assessment of Tachycardia Severity

• A heart rate of 137 beats per minute is significantly elevated and requires prompt medical management, particularly if sustained, as it can lead to deterioration of ventricular function (tachycardia-induced cardiomyopathy) 1
• Patients who are symptomatic with rapid ventricular rates should receive prompt medical management, and cardioversion should be considered if symptomatic hypotension, angina, or heart failure is present 1
• Sustained, uncontrolled tachycardia may lead to deterioration of ventricular function that improves with adequate rate control 1

Immediate Management Before Discharge

• Measurement of heart rate at rest and control of the rate using pharmacological agents (either a beta-blocker or nondihydropyridine calcium channel antagonist) is recommended for patients with persistent tachycardia 1
• For patients with heart failure and tachycardia, intravenous administration of digoxin or amiodarone is recommended to control the heart rate 1
• The target heart rate should be between 60-80 beats per minute at rest and between 90-115 beats per minute during moderate exercise 1

Discharge Criteria

• Before discharge, the patient's heart rate should be adequately controlled with oral medications, with target rates below 110 beats per minute at minimum 2
• Patients with a heart rate of 137 are at risk for developing tachycardia-induced cardiomyopathy, which can develop within an average of 26 days of sustained tachyarrhythmia 3
• Comprehensive discharge instructions should include medication adherence, daily weight monitoring, and clear instructions on what to do if symptoms worsen 1

Cardiology Referral Timing

• While cardiology referral is appropriate, it should not substitute for achieving adequate rate control before discharge 1, 2
• For patients with recurrent or refractory tachycardia, an urgent rather than routine cardiology evaluation should be arranged 2
• If the tachycardia cannot be controlled adequately with first-line agents, the patient should remain hospitalized until adequate control is achieved or a cardiologist evaluates the patient 1

Potential Complications of Untreated Tachycardia

• Tachycardia-induced cardiomyopathy can develop rapidly (within weeks) in patients with uncontrolled tachycardia and may not immediately reverse upon rate control 3, 4
• Even after recovery from cardiac dysfunction due to tachycardia, patients remain at risk for recurrent heart failure and sudden death, indicating the need for careful follow-up 3
• Neurologic complications can occur with sustained tachyarrhythmias, including syncope, dizziness, and potentially stroke if the tachycardia is associated with atrial fibrillation 5

Conclusion

A heart rate of 137 requires intervention to achieve adequate rate control before discharge, regardless of improvement in other symptoms. The patient should be started on appropriate rate control medications and monitored until the heart rate is adequately controlled, ideally to 60-80 beats per minute at rest. While cardiology referral is appropriate, it should not replace achieving adequate rate control before discharge.