How to manage tachycardia in a patient with pleural mesothelioma?

Management of Tachycardia in Pleural Mesothelioma

First, identify and treat the underlying cause of tachycardia rather than the heart rate itself, as tachycardia in mesothelioma patients is typically a symptom of disease burden, pain, anxiety, or complications rather than a primary cardiac problem.

Systematic Approach to Evaluation

Exclude Comorbidities and Complications

• Rule out cardiac failure, chest infection, and pericardial effusion as these are common in mesothelioma and require specific treatment 1
• Pericardial effusion occurs in mesothelioma patients and can cause tachycardia; consider echocardiography if clinically suspected 2, 3
• Supraventricular tachycardia and pericardial effusion have been documented in 20% and 15% of mesothelioma patients receiving certain chemotherapy regimens 2

Address Primary Symptom Drivers

Pain Management:

• Tachycardia often reflects inadequately controlled pain in mesothelioma 1
• Follow cancer pain management principles using opiates as the foundation 1
• Add adjunct analgesia (neuropathic agents) frequently required due to complex pain mechanisms 1
• Seek specialist pain management consultation for refractory cases 1
• Consider palliative radiotherapy for painful tumor nodules 1

Dyspnea and Anxiety Management:

• Low-dose oral morphine reduces dyspnea sensation and associated anxiety, which commonly drive tachycardia 1
• Perform early talc pleurodesis to prevent recurrent effusions before loculation occurs 1, 4
• Use oxygen only if oxygen saturation is reduced 1
• Simple fan creating cool air across the face may reduce dyspnea via trigeminal nerve stimulation 1

When to Consider Rate Control Medications

Important Caveats About Beta-Blockers

Beta-blockers like metoprolol may mask tachycardia but do not address the underlying problem and carry significant risks in this population 5:

• Can precipitate heart failure and cardiogenic shock in patients with compromised cardiac function 5
• May exacerbate bronchospastic disease, which is problematic given the high dyspnea burden in mesothelioma 5
• Mask hypoglycemia symptoms in patients with poor oral intake 5

Appropriate Use of Rate Control

• Consider rate control only after addressing pain, dyspnea, anxiety, and excluding complications
• If beta-blockade is necessary, use the lowest possible dose and monitor closely for bradycardia, heart block, and worsening heart failure 5
• Ensure bronchodilators are readily available if using beta-blockers 5

Supportive Care Framework

Psychological Support:

• Provide specialist nurse support, psychological services, and asbestos support group referrals as anxiety contributes to tachycardia 1

Systemic Therapy:

• Offer pemetrexed plus platinum-based chemotherapy to improve survival and quality of life, which may reduce overall symptom burden including tachycardia 1, 4
• Consider bevacizumab addition in selected patients without contraindications 1, 4

Common Pitfalls to Avoid

• Do not treat the heart rate number without identifying the cause - tachycardia is a symptom, not the disease
• Avoid beta-blockers as first-line therapy when pain, dyspnea, or anxiety are inadequately controlled
• Do not delay pleurodesis in patients with recurrent effusions, as this becomes less effective once loculation occurs 1, 4
• Recognize that mesothelioma has high symptom burden (fatigue, dyspnea, pain, insomnia, cough, anorexia) that collectively contribute to tachycardia 1