Management of Tachycardia (Heart Rate 120 bpm) in an 80-Year-Old Nursing Home Patient
Before administering any medication, you must immediately determine whether this tachycardia is hemodynamically stable or unstable, and obtain a 12-lead ECG to identify the underlying rhythm—this will dictate whether you need emergency cardioversion or can proceed with pharmacologic management. 1
Immediate Assessment Required
Check for hemodynamic instability immediately: Look for hypotension, altered mental status, chest pain, severe dyspnea, or signs of shock. 1 If any of these are present, the patient requires immediate DC cardioversion rather than medications. 1
Obtain a 12-lead ECG immediately to determine if this is: 1, 2
- Narrow-complex tachycardia (QRS <120 ms) suggesting supraventricular origin
- Wide-complex tachycardia (QRS ≥120 ms) suggesting ventricular tachycardia or SVT with aberrancy
- Atrial fibrillation with rapid ventricular response
- Sinus tachycardia from an underlying cause
If Hemodynamically Stable: Pharmacologic Management
For Narrow-Complex Regular Tachycardia (Likely SVT)
First-line treatment is intravenous adenosine (6 mg rapid IV push, followed by 12 mg if needed), which is preferred due to its rapid onset and short half-life. 1, 3
Alternative agents if adenosine fails or is contraindicated:
- Intravenous beta-blockers (metoprolol 2.5-5 mg IV over 2 minutes, may repeat) 1
- Intravenous calcium channel blockers (diltiazem 0.25 mg/kg IV over 2 minutes or verapamil 2.5-5 mg IV) 1
For Atrial Fibrillation with Rapid Ventricular Response
Beta-blockers and diltiazem are the drugs of choice for acute rate control. 1 In this elderly nursing home patient:
- Intravenous metoprolol 2.5-5 mg over 2 minutes, repeat every 5 minutes as needed (maximum 15 mg) 1
- Intravenous diltiazem 0.25 mg/kg (typically 15-20 mg) over 2 minutes 1
If the patient has heart failure, use digoxin or amiodarone instead of beta-blockers or calcium channel blockers, as these can worsen heart failure. 1
For Wide-Complex Tachycardia (Presumed Ventricular Tachycardia)
Treat as ventricular tachycardia until proven otherwise in an 80-year-old patient. 1 If hemodynamically stable:
- Intravenous amiodarone 150 mg over 10 minutes, then 1 mg/min infusion for 6 hours 1
- Intravenous procainamide (if no heart failure or acute MI) 20-50 mg/min until arrhythmia suppressed, hypotension occurs, QRS widens by 50%, or 17 mg/kg given 1
Do NOT use adenosine if pre-excitation (WPW syndrome) is suspected, as this can precipitate ventricular fibrillation. 1, 2
Critical Considerations for This 80-Year-Old Patient
Age-specific caution: In patients ≥85 years or with moderate-to-severe frailty, beta-blockers should be avoided unless there are compelling indications, and long-acting dihydropyridine calcium channel blockers are preferred. 1 However, for acute tachycardia management, short-acting IV agents are still appropriate.
Check for orthostatic hypotension before treatment, as this is common in elderly nursing home patients and may influence medication choice. 1
Target heart rate ≤60 bpm if acute aortic syndrome is suspected (though less likely given the clinical context), using intravenous beta-blockers as first-line. 1
Identify and Treat Underlying Causes
Sinus tachycardia at 120 bpm in an elderly nursing home patient is most commonly secondary to: 4
- Infection (pneumonia, urinary tract infection, sepsis)
- Dehydration or hypovolemia
- Anemia
- Hypoxia
- Pain
- Hyperthyroidism
- Heart failure exacerbation
- Pulmonary embolism
Do not treat sinus tachycardia with antiarrhythmics—treat the underlying cause. 4 Check vital signs including temperature, oxygen saturation, blood pressure, and assess for signs of infection, dehydration, or respiratory distress.
Common Pitfalls to Avoid
Do not assume this is "just anxiety" without proper cardiac evaluation, as supraventricular tachycardia is frequently misdiagnosed as anxiety or panic disorder in elderly patients. 2, 5
Do not use calcium channel blockers or beta-blockers if the patient has severe heart failure or cardiogenic shock, as these can worsen hemodynamics. 1
Do not use AV nodal blocking agents if pre-excitation (delta waves) is present on ECG, as this is dangerous in atrial fibrillation with WPW syndrome. 2
Recognize that persistent tachycardia can cause tachycardia-induced cardiomyopathy, which is reversible if the arrhythmia is controlled. 6
Monitoring During Treatment
Continuous ECG monitoring and pulse oximetry are mandatory. 1 Check blood pressure frequently during medication administration, as hypotension is a common adverse effect of rate-control agents in elderly patients.