What is the empiric treatment for a patient experiencing frequent tachycardia 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 frequent tachycardia without chest pain, with asthma and poorly controlled diabetes, I recommend starting with a non-dihydropyridine calcium channel blocker like diltiazem 120-360mg daily in divided doses, as beta-blockers are generally contraindicated in patients with asthma 1. This approach is based on the most recent and highest quality study available, which prioritizes the patient's safety and well-being. The use of diltiazem is supported by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia, which recommends oral verapamil or diltiazem for ongoing management in patients with AVNRT who are not candidates for, or prefer not to undergo, catheter ablation 1. Some key points to consider when treating this patient include:

• Avoiding beta-blockers due to the patient's asthma, as they can precipitate bronchospasm 1
• Monitoring for potential side effects of diltiazem, such as hypotension and bradycardia 1
• Addressing the underlying diabetes management, including encouraging medication compliance and considering referral to an endocrinologist
• Further investigation of the tachycardia's cause, including thyroid function tests, electrolyte panel, and possibly Holter monitoring or echocardiography
• Advising the patient to avoid caffeine, alcohol, and other stimulants that may exacerbate tachycardia. Additionally, it is essential to consider the patient's non-compliance with diabetic medications and develop a plan to improve adherence, as uncontrolled diabetes can have significant implications for morbidity, mortality, and quality of life.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Myocardial Infarction Early Treatment During the early phase of definite or suspected acute myocardial infarction, initiate treatment with metoprolol tartrate as soon as possible after the patient’s arrival in the hospital.

The FDA drug label does not answer the question about the empiric treatment for a patient experiencing frequent tachycardia without chest pain, with a past medical history of asthma and diabetes, and non-compliance with diabetic medications. The provided drug labels discuss the treatment of myocardial infarction, hypertension, and angina pectoris, but do not directly address the treatment of tachycardia in the context of asthma and diabetes. Therefore, no conclusion can be drawn from the provided information.

From the Research

Empiric Treatment for Tachycardia

The empiric treatment for a patient experiencing frequent tachycardia without chest pain, with a past medical history of asthma and diabetes, and non-compliance with diabetic medications is complex and requires careful consideration of the patient's co-morbidities.

• The use of beta-blockers, such as metoprolol, may be effective in reducing heart rate, but their use in patients with asthma requires caution due to the risk of bronchoconstriction 2, 3.
• Calcium channel blockers, such as diltiazem, may be a reasonable alternative for heart rate control, particularly in patients with asthma or bronchospastic disease 3.
• Ivabradine, a new agent that inhibits sinus node I(f) current, may be effective in reducing heart rate without hemodynamic compromise and is well-tolerated 4.
• The treatment of supraventricular tachycardia, a common type of tachycardia, typically involves the use of vagal maneuvers, calcium channel blockers, or beta-blockers, with catheter ablation being an option for patients with persistent or recurrent symptoms 5.

Considerations for Patients with Diabetes

• Beta-blockers, particularly those with high beta-1 selectivity, may be beneficial in reducing cardiovascular events and mortality in patients with diabetes, especially those with ischemic heart disease or hypertension 6.
• However, the use of beta-blockers in patients with diabetes requires careful consideration of the patient's individual characteristics, such as age, sympathetic activity, and arterial compliance 6.

Considerations for Patients with Asthma

• Non-selective beta-blockers should be avoided in patients with asthma due to the risk of bronchoconstriction, while cardio-selective beta-blockers may be used with caution in low doses 2.
• Alternative treatments, such as calcium channel blockers or ivabradine, may be preferred in patients with asthma 4, 3.