What is the best course of action for a patient with significant heart rate fluctuations, coronary artery disease, atrial fibrillation, and ischemic cardiomyopathy?

Management of Patient with Significant Heart Rate Fluctuations and Complex Cardiac Comorbidities

Primary Recommendation

Proceed with the planned pacemaker implantation referral to Dr. Garcia as the priority intervention, given the documented severe bradycardia (28 bpm at night) and significant heart rate variability (28-121 bpm) in a patient with atrial fibrillation on beta-blocker therapy. 1, 2

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Immediate Assessment at This Visit

Verify Current Clinical Status

• Assess for symptoms of bradycardia, including syncope, presyncope, dizziness, fatigue, or exercise intolerance that would indicate urgent pacemaker need 3
• Check current vital signs with particular attention to resting heart rate and blood pressure to confirm stability on current metoprolol 100 mg daily 1
• Review home heart rate logs to document the pattern and frequency of bradycardic episodes (particularly the documented 28 bpm nocturnal rates) 1
• Evaluate for signs of hemodynamic compromise, including hypotension, acute pulmonary edema, or worsening heart failure symptoms 3

Confirm Pacemaker Planning

• Verify insurance approval status for the Micra leadless pacemaker procedure that was pending at last visit 4
• Confirm Dr. Garcia has contacted the patient to schedule the procedure as documented in the prior visit plan 4
• Document that the patient understands the indication: the combination of symptomatic bradycardia (28 bpm) and need for continued beta-blockade for atrial fibrillation rate control necessitates pacemaker support 3, 1

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Rate Control Strategy Pending Pacemaker

Current Beta-Blocker Management

• Continue metoprolol succinate 100 mg once daily as this provides essential rate control for atrial fibrillation, though it contributes to bradycardia 3
• Do not reduce beta-blocker dose despite bradycardia, as the pacemaker will address this issue while maintaining necessary rate control for AF 1, 2
• Beta-blockers remain the preferred first-line therapy for rate control in patients with atrial fibrillation and coronary artery disease, as they control heart rate, improve ventricular function, and prolong survival 2

Avoid Medication Changes That Could Worsen Bradycardia

• Do not add digoxin at this time, as it can exacerbate bradycardia and is contraindicated in patients with significant bradyarrhythmias without pacemaker protection 3, 1
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) given the reduced ejection fraction of 45% and risk of further bradycardia 3, 1

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Anticoagulation Management

Continue Current Regimen

• Continue Eliquis (apixaban) 5 mg twice daily for stroke prevention in atrial fibrillation 3
• Verify appropriate dosing based on current renal function, age, and weight (standard dose is appropriate unless patient has ≥2 of: age ≥80, weight ≤60 kg, or creatinine ≥1.5 mg/dL) 3
• Anticoagulation must continue indefinitely regardless of pacemaker implantation, as device placement does not eliminate stroke risk from atrial fibrillation 3

Periprocedural Anticoagulation Planning

• Direct oral anticoagulants are recommended in preference to warfarin for patients undergoing device procedures 3
• Coordinate with Dr. Garcia regarding perioperative anticoagulation management for the Micra implantation procedure 4

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Heart Failure Management

Optimize Guideline-Directed Medical Therapy

• Continue spironolactone 25 mg daily for heart failure with reduced ejection fraction (EF 45%) 3
• Continue furosemide 20 mg daily for volume management, adjusting based on clinical volume status 3
• Continue losartan 50 mg daily for blood pressure control and neurohormonal blockade in heart failure 3
• Assess volume status by examining for peripheral edema, jugular venous distension, and pulmonary congestion 1

Monitor for Decompensation

• Verify patient continues to have resolution of leg swelling as reported at last visit 3
• Confirm patient is monitoring daily weights and instructed to report weight gain >2-3 pounds in 24 hours or >5 pounds in one week 3
• Reinforce dietary sodium restriction (<2 grams daily) and fluid management strategies 3

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Coronary Artery Disease Management

Continue Secondary Prevention

• Continue aspirin 81 mg daily for coronary artery disease with prior stent placement 3, 5
• Continue atorvastatin 40 mg daily with LDL goal <70 mg/dL given high-risk CAD 6
• Verify patient has not required PRN isosorbide mononitrate for chest pain, confirming stable anginal status 3

Dual Antiplatelet Considerations

• Confirm duration since last stent placement (left circumflex proximal stent noted as open on 8/20/2025 catheterization) 5
• The combination of aspirin plus Eliquis is appropriate for patients with both atrial fibrillation and coronary artery disease with remote stenting 5, 7
• Triple therapy (aspirin + P2Y12 inhibitor + anticoagulant) is not indicated beyond 12 months post-stent in stable patients 5

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Pacemaker-Specific Considerations

Micra Leadless Pacemaker Advantages

• The Micra leadless pacemaker eliminates transvenous lead and pocket-related complications, which is particularly advantageous in this patient with multiple comorbidities 4, 8
• Single femoral approach allows concurrent AV node ablation if needed for refractory rate control, though this is not currently planned 4, 9
• Excellent device performance with stable sensing and pacing thresholds has been demonstrated in similar patient populations 4, 8

Safety Considerations

• Maintain safe distance (≥35 mm) from Micra device if any future ablation procedures are performed to prevent acute pacing threshold elevation 9
• Device infection risk is minimal compared to traditional pacemakers due to absence of pocket and leads 4, 8
• No device dislodgement or malfunction has been reported in medium-term follow-up studies of similar patients 4

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Follow-Up Planning

Immediate Next Steps

• Expedite pacemaker implantation if insurance approval is complete and patient is symptomatic from bradycardia 3, 1
• Schedule 4-week follow-up as planned, or sooner if pacemaker is implanted 3
• Provide clear instructions to call 911 if chest pain persists >10 minutes or if syncope/presyncope occurs 3

Post-Pacemaker Management

• Device interrogation at 2 weeks, 3 months, and then every 6 months to assess pacing thresholds, battery status, and percentage of ventricular pacing 4
• Continue all cardiac medications including beta-blocker at current or potentially higher doses once pacemaker provides backup pacing 1, 2
• Reassess rate control adequacy with ambulatory monitoring after pacemaker implantation to ensure heart rate targets are met 1

Long-Term Cardiology Care Transition

• Address the care transition plan given uncertainty about Dr. Garcia's practice situation and potential retirement 3
• Establish clear follow-up either with current provider until December 1st or transition to Dr. Garcia for ongoing management 3
• Ensure continuity of device monitoring regardless of which cardiologist provides primary cardiac care 4

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Critical Pitfalls to Avoid

• Do not reduce or discontinue beta-blocker prior to pacemaker implantation despite bradycardia, as this will worsen atrial fibrillation rate control and increase risk of rapid ventricular response 1, 2
• Do not delay pacemaker implantation in a patient with documented 28 bpm nocturnal heart rates, as this represents severe symptomatic bradycardia requiring device therapy 3, 1
• Do not discontinue anticoagulation after pacemaker placement, as atrial fibrillation stroke risk persists regardless of device implantation 3
• Avoid adding digoxin or calcium channel blockers for rate control in a patient with significant bradycardia and reduced ejection fraction without pacemaker protection 3, 1
• Do not assume rate control is adequate based on resting heart rate alone; the documented tachycardia to 121 bpm indicates inadequate rate control during activity that will need reassessment post-pacemaker 1