How to proceed with a patient on hemodialysis (HD) with atrial fibrillation (AF) and tachycardia, who has received Bisoprolol (beta blocker) 10mg, and has stable blood pressure?

From the Guidelines

For a patient on hemodialysis with fast atrial fibrillation (AF) at a heart rate of 150 bpm but stable blood pressure who has already received bisoprolol 10 mg, I recommend continuing the hemodialysis session with close monitoring while implementing additional rate control measures, such as administering intravenous diltiazem or metoprolol IV, as outlined in the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1. The patient's current heart rate of 150 bpm indicates the need for further rate control to prevent potential complications such as decreased cardiac output and increased risk of thromboembolism.

• Consider administering intravenous diltiazem (initial bolus of 0.25 mg/kg over 2 minutes, followed by infusion at 5-15 mg/hour) as recommended in the guideline 1.
• Alternatively, metoprolol IV (5 mg slow IV push, may repeat every 5 minutes for a total of 15 mg) can be considered if the heart rate remains elevated despite the bisoprolol, as per the guideline's recommendations for AF rate control 1. Ensure continuous cardiac monitoring throughout dialysis and check electrolytes, particularly potassium and magnesium levels, as imbalances can worsen arrhythmias, as suggested by the guideline's emphasis on monitoring and managing electrolyte imbalances in patients with AF 1. If the patient develops hemodynamic instability during dialysis, be prepared to slow or temporarily pause ultrafiltration to maintain cardiovascular stability, in line with the guideline's recommendations for managing patients with AF and heart failure 1. After completing dialysis, obtain a 12-lead ECG and consider cardiology consultation for long-term management of AF, which may include anticoagulation assessment (using CHA₂DS₂-VASc score), rhythm control strategies, or cardioversion if appropriate, as outlined in the guideline's recommendations for the management of patients with AF 1.

From the Research

Patient Assessment

• The patient is currently undergoing hemodialysis and is in fast atrial fibrillation (AF) with a heart rate of 150.
• The patient's blood pressure is stable, and they have already received bisoprolol 10 mg.
• The patient's condition requires careful management to prevent major cardiovascular events.

Management Considerations

• According to the study 2, the optimal blood pressure (BP) treatment target for patients with AF undergoing hypertension treatment is 120 to 129/<80 mm Hg.
• The study 2 suggests that patients with AF and newly redefined hypertension (BP ≥130/80 mm Hg) are at higher risk of major cardiovascular events.
• The patient's current heart rate of 150 may require further management to reduce the risk of cardiovascular events.
• The use of bisoprolol 10 mg may help to control the patient's heart rate, but further monitoring and adjustment of treatment may be necessary.

Next Steps

• Continue to monitor the patient's blood pressure, heart rate, and overall condition during the hemodialysis session.
• Consider adjusting the patient's treatment plan to achieve the optimal BP target of 120 to 129/<80 mm Hg, as suggested by the study 2.
• Further evaluation and management of the patient's AF and hypertension may be necessary to reduce the risk of major cardiovascular events.