What is the first-line medication to introduce for a 91-year-old woman with dementia and comfort goals of care, presenting with chronic sinus tachycardia (EKG showing sinus tachycardia), who is asymptomatic with normal blood pressure?

From the Guidelines

For a 91-year-old woman with dementia, comfort goals of care, and asymptomatic chronic sinus tachycardia with heart rate in the 130s and normal blood pressure, the first-line medication to consider would be ivabradine, given its effectiveness in reducing heart rate without affecting blood pressure, as recommended in the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. Given her advanced age and dementia, it's crucial to prioritize medications that are less likely to cause hypotension or excessive bradycardia. Ivabradine, by specifically inhibiting the I(f) channel in the sinoatrial node, reduces heart rate without significantly affecting contractility or ventricular repolarization, making it a preferable option in this context. The dosage of ivabradine could start at 2.5 mg twice daily, with careful monitoring of heart rate response and adjustment as needed, considering the patient's comfort and potential for side effects such as phosphenes. Beta-blockers, such as metoprolol, could be considered as an alternative or in combination with ivabradine if the patient remains symptomatic, despite the potential for more side effects like hypotension or fatigue, as noted in the guideline 1. However, given the patient's asymptomatic status and the goal of maintaining comfort, the focus should be on minimizing interventions that could potentially reduce quality of life, making ivabradine a more suitable initial choice. Key considerations in managing this patient include:

• Monitoring for signs of heart failure or worsening dementia that could influence medication choice
• Regular assessment of the patient's comfort level and potential subtle distress that could be attributed to tachycardia
• Collaboration with the patient's caregivers and healthcare team to ensure that any medication adjustments align with the patient's comfort goals of care.

From the FDA Drug Label

In general, use a low initial starting dose in elderly patients given their greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. The first line medication to introduce for a 91-year-old woman with dementia and asymptomatic sinus tachycardia would be metoprolol, starting with a low initial dose.

• The dose should be titrated cautiously according to clinical response, considering the patient's geriatric status and potential for decreased hepatic, renal, or cardiac function 2.
• It is essential to monitor the patient's heart rate and rhythm during metoprolol therapy, as bradycardia can occur 2.

From the Research

Treatment of Inappropriate Sinus Tachycardia

• In a patient with comfort goals of care and asymptomatic sinus tachycardia, the treatment approach should prioritize the patient's quality of life and comfort 3, 4, 5.
• The first line medication to introduce for inappropriate sinus tachycardia is often a beta-blocker, such as metoprolol succinate, or an I(f) channel inhibitor, such as ivabradine 6, 7.
• Ivabradine has been shown to be effective in reducing heart rate and relieving symptoms in patients with inappropriate sinus tachycardia, and may be better tolerated than beta-blockers in some patients 7.

Considerations for Patients with Dementia

• Patients with advanced dementia may not benefit from aggressive medical interventions, and a palliative care approach focused on comfort and quality of life may be more appropriate 3, 4, 5.
• The goals of care for patients with dementia should be individualized and take into account the patient's values, preferences, and prognosis 3, 4, 5.
• Family and professional caregivers play an important role in establishing and implementing comfort care goals for patients with dementia 4, 5.

Medication Options

• Metoprolol succinate and ivabradine are both potential options for treating inappropriate sinus tachycardia in patients with comfort goals of care 6, 7.
• The choice of medication should be based on the patient's individual needs and medical history, as well as their tolerance of potential side effects 7.