What should be done for tachycardia and potential hypertension?

Management of Tachycardia with Heart Rate 124 and Blood Pressure 112

With a heart rate of 124 bpm and blood pressure of 112 mmHg, immediately assess for signs of hemodynamic instability (altered mental status, chest pain, acute heart failure, hypotension, or shock) and identify the underlying cause, as this heart rate is below the 150 bpm threshold where tachycardia itself typically causes symptoms, making it most likely a physiologic response to an underlying condition rather than a primary arrhythmia. 1

Immediate Assessment Steps

Determine if the patient is stable or unstable:

• Attach cardiac monitor, obtain vital signs, establish IV access, and assess oxygen saturation 1, 2
• Check for signs of hemodynamic instability: acute altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or other signs of shock 1
• Assess respiratory status for signs of increased work of breathing (tachypnea, intercostal retractions, suprasternal retractions, paradoxical abdominal breathing) as hypoxemia is a common cause of tachycardia 1
• Obtain a 12-lead ECG to define the rhythm, but do not delay treatment if the patient is unstable 1, 2

Critical Decision Point: Heart Rate <150 bpm

At a heart rate of 124 bpm, symptoms of instability are unlikely to be caused primarily by the tachycardia unless there is impaired ventricular function. 1 In the absence of ventricular dysfunction, this tachycardia is more likely secondary to an underlying condition causing both the presenting symptoms and the faster heart rate. 1

Identify and Treat Underlying Causes

Focus on identifying reversible causes rather than treating the heart rate itself:

• Sinus tachycardia (most likely at this rate) results from physiologic stimuli such as fever, anemia, hypotension/shock, dehydration, hypoxemia, pain, anxiety, hyperthyroidism, or sepsis 1
• No specific drug treatment is required for sinus tachycardia—therapy should be directed toward identification and treatment of the underlying cause 1
• When cardiac function is poor, cardiac output can be dependent on a rapid heart rate, and "normalizing" the heart rate can be detrimental 1

Blood Pressure Considerations

A blood pressure of 112 mmHg (assuming systolic) is not hypertensive and does not require acute blood pressure lowering:

• Hypertensive urgency is defined as diastolic BP >120 mmHg without acute target organ damage 3, 4
• Hypertensive emergency requires BP >180/120 mmHg with evidence of new or worsening organ damage 4
• This blood pressure reading does not meet criteria for either urgency or emergency 3, 4

When to Consider Rate Control

If the patient has chronic hypertension with resting heart rate >80-85 bpm, investigate for:

• Occult heart failure symptoms by clinical examination, biomarkers (BNP), or echocardiogram 1, 2
• Associated comorbidities such as atrial fibrillation, atrial flutter, anemia, hyperthyroidism, or sepsis 1
• Sleep apnea or sleep-disordered breathing, which is more common in hypertensive patients 1

Beta-blockers or other heart rate-lowering agents may be considered in hypertensive patients with persistently elevated resting heart rate (>80-85 bpm) after excluding reversible causes. 1

Specific Management for Supraventricular Tachycardia (If Identified)

If the 12-lead ECG reveals a supraventricular tachycardia rather than sinus tachycardia:

• For hemodynamically stable patients with regular narrow-complex SVT, attempt vagal maneuvers first 1
• Intravenous adenosine (6 mg rapid IV push, followed by 12 mg if required) is recommended as initial therapy 1
• Intravenous beta-blockers (especially esmolol for short-term control), diltiazem, or verapamil are recommended for hemodynamically stable patients 1
• For hemodynamically unstable patients, proceed to immediate synchronized cardioversion 1

Critical Pitfalls to Avoid

• Never aggressively lower heart rate in compensatory sinus tachycardia, as stroke volume may be limited and cardiac output dependent on the elevated heart rate 1
• Never use AV nodal blocking agents if pre-excitation is present on ECG, as this can be dangerous in atrial fibrillation with WPW syndrome 2, 5
• Never delay cardioversion in unstable patients while obtaining a 12-lead ECG 2
• Never give adenosine for irregular or polymorphic wide-complex tachycardia, as it may cause degeneration to ventricular fibrillation 2, 5

Follow-Up and Monitoring

After identifying and treating the underlying cause:

• Monitor for resolution of tachycardia as the underlying condition improves 1
• If tachycardia persists despite treatment of reversible causes, consider ambulatory monitoring (Holter or event recorder) to capture the rhythm during symptomatic episodes 5
• Refer to cardiology or electrophysiology if wide-complex tachycardia of unknown origin, recurrent paroxysmal palpitations with abrupt onset/termination, or drug-resistant/intolerant narrow-complex tachycardia is present 2, 5