From the Guidelines
For a heart rate of 123 beats per minute, intravenous beta blockers, diltiazem, or verapamil is recommended as the first line of treatment in hemodynamically stable patients with suspected focal atrial tachycardia, as stated in the 2015 ACC/AHA/HRS guideline 1. This approach is based on the guideline's recommendation for acute treatment in such cases, emphasizing the use of these medications to either terminate the focal atrial tachycardia or slow the ventricular rate.
Key Considerations:
- The choice between beta blockers, diltiazem, and verapamil should be based on the patient's specific clinical context, including any underlying conditions that might contraindicate one of these options.
- Close monitoring is crucial during intravenous drug therapy to evaluate for potential side effects such as hypotension or bradycardia, as noted in the guideline 1.
- For patients who are hemodynamically unstable, synchronized cardioversion is recommended as an acute treatment, according to the guideline 1.
- Adenosine can be useful in the acute setting for diagnosing the tachycardia mechanism or restoring sinus rhythm, especially in cases of suspected focal atrial tachycardia of a triggered mechanism, as suggested by the guideline 1.
Treatment Options:
- Intravenous beta blockers: Effective in slowing the heart rate and can be used in hemodynamically stable patients.
- Diltiazem or verapamil: Calcium channel blockers that can also slow the heart rate and are recommended for use in hemodynamically stable patients with focal atrial tachycardia.
- Synchronized cardioversion: Recommended for patients with hemodynamically unstable focal atrial tachycardia.
- Adenosine: Useful for diagnosis and treatment in specific cases, particularly those with a triggered mechanism. It's essential to tailor the treatment approach to the individual patient's condition, considering factors such as the presence of underlying heart disease, the specific mechanism of the tachycardia if known, and the patient's overall clinical stability, as emphasized by the guideline recommendations 1.
From the FDA Drug Label
Bradycardia Bradycardia, including sinus pause, heart block, and cardiac arrest have occurred with the use of metoprolol. The FDA drug label does not answer the question.
From the Research
Treatment Options for Heart Rate 123
- For a heart rate of 123, which may be indicative of supraventricular tachycardia (SVT), treatment options include vagal maneuvers, adenosine, calcium channel blockers, and beta blockers 2, 3, 4, 5.
- Vagal maneuvers are often the first line of treatment for SVT, and if unsuccessful, adenosine can be administered 2, 4, 5.
- Calcium channel blockers (diltiazem or verapamil) or beta blockers (metoprolol) can be used acutely or as long-term therapy for SVT 2.
- Class Ic antiarrhythmics (flecainide or propafenone) can be used long-term, while Class Ia antiarrhythmics (quinidine, procainamide, or disopyramide) are used less often due to their modest effectiveness and adverse effects 2.
- Catheter ablation has a high success rate and is recommended as the first-line method for long-term management of recurrent, symptomatic paroxysmal SVT, including Wolff-Parkinson-White syndrome 2, 4.
Acute Management
- In patients who are hemodynamically unstable, synchronized cardioversion is first-line management 4.
- In those who are hemodynamically stable, vagal maneuvers are first-line management, followed by stepwise medication management if ineffective 4.
- High-dose adenosine may be considered for refractory SVT, but this should be done in consultation with a cardiologist 3.
Long-term Management
- Long-term treatment is dependent on several factors, including frequency of symptoms, risk stratification, and patient preference 5.
- Management can range from conservative, if symptoms are rare and the patient is low risk, to catheter ablation, which is curative in the majority of patients 5.
- Beta blockers and/or calcium channel blockers may be used acutely or for long-term suppressive therapy 4, 5.