What alternative treatments can be considered for a patient experiencing persistent palpitations, premature ventricular contractions (PVCs), and paroxysmal atrial tachycardias (PATs) despite an increased dose of metoprolol (beta blocker) to 150mg, with normal blood pressure readings and fatigue?

From the Guidelines

I strongly recommend considering catheter ablation of the slow pathway as a potentially curative treatment for your AVNRT, given the high success rates and low risk of complications, as supported by the 2015 ACC/AHA/HRS guideline 1. Given your symptoms of continued fluttering, PVCs, and PATs despite metoprolol increase to 150mg, and considering your blood pressure is well-controlled, we should explore alternative treatment options.

• The current metoprolol dose may not be sufficient to control your arrhythmias, and increasing it further may not be tolerated due to the morning fatigue you're experiencing.
• Adding a calcium channel blocker such as diltiazem or verapamil, as recommended by the guideline 1, may help control your arrhythmias, but it's essential to weigh the potential benefits against the risks of bradyarrhythmias and hypotension.
• Flecainide or propafenone may be considered as alternative treatments, but they are generally reserved for patients without structural heart disease or ischemic heart disease, and their use requires careful consideration of the potential risks of proarrhythmia 1.
• Catheter ablation of the slow pathway, on the other hand, has a high success rate (>95%) and a low risk of complications (<1% risk of AV block), making it a highly effective treatment option for AVNRT, as stated in the guideline 1. It's crucial to discuss the potential benefits and risks of each treatment option with your healthcare provider to determine the best course of action for your specific situation.
• Additionally, lifestyle modifications such as reducing caffeine, alcohol, and stress, as well as checking and supplementing electrolytes like potassium and magnesium, may help alleviate your symptoms.
• The guideline also recommends clinical follow-up without pharmacological therapy or ablation for minimally symptomatic patients with AVNRT, but since your symptoms are bothersome, this option may not be suitable for you 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Symptoms and Current Treatment

• The patient is experiencing continued fluttering, PVCs, and PATs despite an increased dose of metoprolol to 150mg, taken at night.
• The patient notices increased tiredness in the morning.
• Blood pressure is well-controlled, with systolic readings between 115-120 and diastolic readings in the 70s.
• The patient has been exercising to lose weight and notices symptoms both at rest and during activity.

Alternative Treatment Options

• According to 2, flecainide, propafenone, and sotalol may be considered as alternative treatments for idiopathic premature ventricular complexes (PVCs).
• Flecainide was found to be the most effective in achieving complete or near-complete reduction of PVCs, compared to propafenone and sotalol.
• Beta-blockers, such as bisoprolol, may also be effective in treating arrhythmias, including supraventricular and ventricular arrhythmias, as shown in 3.

Metoprolol Side Effects and Pharmacokinetics

• Metoprolol is a beta-blocker that can cause side effects such as fatigue, dizziness, and headache, as mentioned in 4.
• The pharmacokinetics of metoprolol, including its half-life and plasma clearance, can vary between individuals, as shown in 5.
• High-dose intravenous metoprolol was found to be well-tolerated in patients with suspected acute myocardial infarction, with a dose-dependent relation between accumulated metoprolol dose and pain relief, as reported in 5.

Considerations for Treatment Adjustment

• The patient's current dose of metoprolol may not be sufficient to control their symptoms, and alternative treatments or dose adjustments may be necessary.
• The patient's blood pressure is well-controlled, but their symptoms of PVCs and PATs persist, suggesting that alternative treatments may be needed to address these specific symptoms.
• The patient's increased tiredness in the morning may be related to their metoprolol dose, and adjusting the dose or switching to a different medication may help alleviate this side effect.