What treatment is indicated for a patient with tachycardia (heart rate of 133 beats per minute)?

From the Guidelines

For a patient with a heart rate of 133 beats per minute, initial management should focus on assessing airway, breathing, and circulation, obtaining vital signs, and performing an ECG to determine the underlying cause of the tachycardia, as the treatment approach may vary depending on whether it is sinus tachycardia or an abnormal rhythm like atrial fibrillation, atrial flutter, or ventricular tachycardia 1. Given the information provided, it's crucial to first evaluate the patient's clinical status and identify potential reversible causes of the tachycardia.

• The patient's symptoms, blood pressure, and medical history are essential factors in determining the appropriate treatment.
• If the patient is unstable with symptoms like chest pain, shortness of breath, altered mental status, or hypotension, immediate medical intervention is required, which may include synchronized cardioversion for patients with hemodynamically unstable focal atrial tachycardia 1.
• For hemodynamically stable patients with focal atrial tachycardia, intravenous beta blockers, diltiazem, or verapamil may be useful for acute treatment 1.
• Adenosine can be considered in the acute setting to either restore sinus rhythm or diagnose the tachycardia mechanism in patients with suspected focal atrial tachycardia 1.
• It's also important to note that the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia provides recommendations for the acute treatment of suspected focal atrial tachycardia, including the use of intravenous beta blockers, diltiazem, or verapamil, and synchronized cardioversion for hemodynamically unstable patients 1. The most critical step is to assess the patient's stability and the underlying cause of the tachycardia to guide the treatment approach, with a focus on improving morbidity, mortality, and quality of life outcomes 1.

From the FDA Drug Label

Esmolol hydrochloride injection is indicated for the short-term treatment of: Control of ventricular rate in supraventricular tachycardia including atrial fibrillation and atrial flutter and control of heart rate in noncompensatory sinus tachycardia Esmolol hydrochloride injection is indicated for the rapid control of ventricular rate in patients with atrial fibrillation or atrial flutter in perioperative, postoperative, or other emergent circumstances where short-term control of ventricular rate with a short-acting agent is desirable Esmolol hydrochloride injection is also indicated in noncompensatory sinus tachycardia where, in the physician’s judgment, the rapid heart rate requires specific intervention.

The treatment indicated for a patient with tachycardia (heart rate of 133 beats per minute) is esmolol hydrochloride injection. The dosage and administration of esmolol hydrochloride injection should be according to the instructions in the drug label, which includes an optional loading dose and a maintenance dose, with titration using ventricular rate or blood pressure at ≥ 4 minute intervals 2, 2.

From the Research

Treatment Options for Tachycardia

• For a patient with a heart rate of 133 beats per minute, treatment options may include:
  • β-Blockers, such as metoprolol or esmolol, which can help control heart rate 3, 4, 5
  • Calcium channel blockers, such as verapamil or diltiazem, which can also help control heart rate 3, 4, 6, 7
• However, the use of β-Blockers and calcium channel blockers together is contraindicated in certain situations, such as in patients with high myocardial susceptibility and vulnerability 3
• In patients with heart failure, diltiazem may not be recommended due to its negative inotropic effects, but studies have shown that it can be effective in controlling heart rate with no significant differences in safety outcomes compared to metoprolol 4

Specific Treatment Considerations

• Esmolol, a cardioselective β-blocker, has been shown to be effective in controlling elevated heart rates and is generally well-tolerated 5
• Verapamil and diltiazem have been shown to improve rhythm pattern and increase latent conduction, but may not be effective in all patients with constant cardiac fibrillation 6
• Calcium channel blockers, such as verapamil or diltiazem, may be effective as a first-line treatment for broad complex tachycardia with right bundle branch block 7