What is the empiric treatment for a patient experiencing tachycardia (rapid heart rate) without chest pain, with a past medical history of asthma and diabetes (diabetes mellitus), and non-compliance with diabetic medications?

From the Guidelines

For a patient experiencing tachycardia without chest pain who has asthma and poorly controlled diabetes, initial empiric treatment should focus on rate control while investigating the underlying cause, and I recommend starting with vagal maneuvers or IV adenosine as first-line treatment strategies, as suggested by the most recent guidelines 1. The patient's asthma and diabetes should be considered when choosing a treatment, and since the patient is non-compliant with diabetic medications, restarting these medications and monitoring blood glucose levels closely is crucial, as hyperglycemia itself can contribute to tachycardia. Some key points to consider in the treatment of this patient include:

• The use of vagal maneuvers, IV adenosine, verapamil, and diltiazem as first-line treatment strategies for narrow-complex tachycardias, as recommended by the 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1.
• The potential for cardioselective beta-blockers, such as metoprolol, to effectively reduce heart rate with minimal impact on the patient's asthma, although they are not the first-line treatment recommended by the most recent guidelines.
• The importance of addressing the patient's uncontrolled diabetes and monitoring blood glucose levels closely, as hyperglycemia can contribute to tachycardia.
• The need to obtain baseline ECG, electrolytes, thyroid function tests, and hemoglobin A1c to identify potential causes of tachycardia. It is essential to prioritize the patient's stability and the rhythm when choosing a treatment, and to consider the potential adverse effects of each treatment option, such as the initiation of AF with adenosine or the potentiation of hypotensive and/or bradycardic effects with concomitant use of IV calcium-channel blockers and beta blockers, as noted in the acc/aha/esc guidelines for the management of patients with supraventricular arrhythmias 1.

From the FDA Drug Label

Verapamil Hydrochloride Injection, USP is indicated for the following: • Rapid conversion to sinus rhythm of paroxysmal supraventricular tachycardias, including those associated with accessory bypass tracts (Wolff-Parkinson-White [W-P-W] and Lown-Ganong- Levine [L-G-L] syndromes). • Temporary control of rapid ventricular rate in atrial flutter or atrial fibrillation except when the atrial flutter and/or atrial fibrillation are associated with accessory bypass tracts (Wolff-Parkinson-White (W-P-W) and Lown-Ganong-Levine (L-G-L) syndromes)

The empiric treatment for a patient experiencing tachycardia (rapid heart rate) without chest pain, with a past medical history of asthma and diabetes, and non-compliance with diabetic medications is verapamil.

• Key considerations:
  • The patient's asthma history may be a concern with certain medications, but verapamil does not have specific warnings regarding asthma.
  • The patient's diabetes history is relevant, as metoprolol may mask tachycardia occurring with hypoglycemia, but verapamil does not have this specific warning.
  • The patient's non-compliance with diabetic medications may increase the risk of hypoglycemia, but this is not directly relevant to the choice of verapamil for tachycardia treatment.
  • Verapamil should be used with caution and in a monitored setting due to the risk of adverse responses, including marked hypotension or extreme bradycardia/asystole 2.
• Alternative options:
  • Metoprolol may be considered, but it is not the first-line treatment for supraventricular tachycardia, and it has specific warnings regarding bronchospastic disease and diabetes 3.

From the Research

Empiric Treatment for Tachycardia

The empiric treatment for a patient experiencing tachycardia without chest pain, with a past medical history of asthma and diabetes, and non-compliance with diabetic medications is as follows:

• The first step is to document the tachycardia, preferably on a 12-lead electrocardiogram (ECG) for diagnosis and management 4.
• Classification of the tachycardia according to its regularity and QRS width is essential to make a differential diagnosis 4.
• For patients with asthma, non-selective β-blockers should not be prescribed due to the risk of asthma worsening 5.
• Cardio-selective β-blockers, such as metoprolol, may be used with caution in patients with asthma, but their efficacy in treating tachycardia is lower compared to other options 5, 6.
• Alternative treatment options for tachycardia include:
  • Vagal maneuvers
  • Adenosine
  • Nondihydropyridine calcium channel blockers, such as verapamil and diltiazem, which are equally efficacious as adenosine in converting AVNRT to sinus rhythm without negative side effects 7
  • Etripamil, a novel intranasal non-dihydropyridine calcium channel blocker, which has shown efficacy in treating paroxysmal supraventricular tachycardias 8

Considerations for Patients with Asthma and Diabetes

• Patients with asthma and diabetes require careful consideration when selecting treatment options for tachycardia.
• The use of β-blockers, including cardio-selective β-blockers, should be approached with caution in patients with asthma due to the potential risk of asthma worsening 5.
• The patient's non-compliance with diabetic medications should also be taken into account when selecting treatment options, as some medications may interact with diabetes medications or exacerbate diabetes-related complications.