What additional treatment can be given to a 90-year-old patient with advanced dementia, atrial fibrillation (a fib), and a brain bleed, who has tachycardia despite being on metoprolol (Metoprolol) 25 mg twice daily and digoxin, with apixaban (Apixaban) held?

From the Guidelines

For a 90-year-old nursing home patient with advanced dementia, known atrial fibrillation, and a recent brain bleed who remains in rapid atrial fibrillation (heart rate 150s) despite metoprolol 25 mg twice daily and digoxin, I would recommend adding diltiazem for rate control, as suggested by the most recent guidelines 1. Consider starting with IV diltiazem 0.25 mg/kg over 2 minutes, followed by an infusion at 5-15 mg/hour if effective, or oral diltiazem 30 mg four times daily if IV administration isn't feasible, as outlined in previous guidelines 1. Given the patient's brain bleed and that apixaban is held, rate control rather than rhythm control is the priority, in line with the latest recommendations 1. The calcium channel blocker diltiazem works by slowing conduction through the AV node, complementing the beta-blockade from metoprolol. Since the patient is elderly with multiple comorbidities, close monitoring for hypotension and bradycardia is essential, as emphasized in the guidelines 1. Considering the family's understanding about comfort measures, discussing goals of care is important while managing symptoms, as part of a patient-centered approach 1. Electrolyte imbalances should also be corrected if present, as they can exacerbate arrhythmias, highlighting the need for comprehensive management. Key points to consider include:

• The patient's advanced age and dementia, which may impact treatment tolerance and goals of care
• The recent brain bleed, which necessitates careful consideration of anticoagulation and rate control
• The importance of monitoring for potential side effects of diltiazem, such as hypotension and bradycardia
• The role of electrolyte balance in managing arrhythmias and overall patient health.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Myocardial Infarction Early Treatment During the early phase of definite or suspected acute myocardial infarction, initiate treatment with metoprolol tartrate as soon as possible after the patient’s arrival in the hospital. Such treatment should be initiated in a coronary care or similar unit immediately after the patient’s hemodynamic condition has stabilized Begin treatment in this early phase with the intravenous administration of three bolus injections of 5 mg of metoprolol tartrate injection each; give the injections at approximately 2-minute intervals. During the intravenous administration of metoprolol tartrate injection, monitor blood pressure, heart rate, and electrocardiogram In patients who tolerate the full intravenous dose (15 mg), initiate metoprolol tartrate tablets, 50 mg every 6 hours, 15 minutes after the last intravenous dose and continued for 48 hours. Thereafter, the maintenance dosage is 100 mg orally twice daily Start patients who appear not to tolerate the full intravenous on metoprolol tartrate tablets either 25 mg or 50 mg every 6 hours (depending on the degree of intolerance) 15 minutes after the last intravenous dose or as soon as their clinical condition allows. In patients with severe intolerance, discontinue metoprolol tartrate (see WARNINGS)

The patient is already on metoprolol 25 mg bid, and the heart rate remains high at 150.

• Considering the patient's condition, intravenous metoprolol could be an option, starting with a dose of 5 mg and monitoring the patient's response.
• Alternatively, other medications such as digoxin (already being used) or amiodarone could be considered to control the heart rate in atrial fibrillation, but this is not directly mentioned in the provided drug labels 2 2.
• However, caution should be exercised when using these medications, especially in a patient with advanced dementia and a brain bleed.
• The primary goal should be to control the patient's symptoms and ensure their comfort, given the family's understanding of transitioning to comfort care if deterioration occurs.

From the Research

Management of Rapid Atrial Fibrillation

• The patient's heart rate remains elevated at 150 despite increased metoprolol dosage, indicating the need for alternative or additional treatments.
• According to the study 3, diltiazem (a calcium channel blocker) may be more effective than metoprolol (a beta-blocker) in achieving rate control in patients with atrial fibrillation or flutter.
• The study 3 found that diltiazem was more rapid and effective in reducing heart rate, with 95.8% of patients reaching a target heart rate of <100 bpm within 30 minutes, compared to 46.4% of patients treated with metoprolol.

Considerations for Treatment

• When considering alternative treatments, it is essential to weigh the potential benefits and risks, including the risk of hypotension or bradycardia.
• The study 3 found no significant difference in the incidence of adverse effects, such as hypotension or bradycardia, between diltiazem and metoprolol.
• Other studies, such as 4, discuss the importance of considering potential side effects of medications, including methemoglobinemia, although this is not directly relevant to the treatment of atrial fibrillation.

Potential Next Steps

• Based on the evidence from 3, diltiazem may be a viable option for managing the patient's rapid atrial fibrillation, either as an alternative or in addition to metoprolol.
• However, it is crucial to carefully evaluate the patient's individual response to treatment and adjust the management plan accordingly.