Question for the cardiac guru's out there

[RunninOnCoffee]

Had a patient come into the office I work in for simple out patient procedure. He was having an Angiogram done on his RLE. This requires a 2 hour recovery period since the doctor does a femoral puncture.

Before the pre-op nurse medicated him, he asked her if we could give him his medications he usually takes at 9am during the recovery period which were Amlodipine 5mg and Carvedilol 6.25mg.

When I got him post op she told me about his request and I said ok, but I would see how he was doing clinically first. As soon as I put on his cardiac leads I noticed he was V-Paced at 60. Often his heart would try to take over but could get no higher than 45 so the pacer kicked in and brought him up to 60 again.

Now here is my question. If his normal unpaced HR cannot even exceed 45-50, why would he be prescribed medications that would suppress the HR more? I asked why he had the pacer placed and if it was a pacer/defib combo but he couldn't tell me. I could understand if he was susceptible to runs of AFib RVR or SVT, however I would expect something more along the lines of Cardizem or Amiodarone. When he was leaving his BP had climbed to the 130's systolic, but I would think another BP med would be more appropriate.

I could very well be missing the bigger picture here, so if someone could please guide me I would appreciate it. I mentioned it to the MD I worked for, but he said it wasn't his specialty and just had me recommend the patient follow up with his cardiologist.

Thanks!!

[tcvnurse, BSN, RN]

Well the carvedilol is a beta blocker. Takes the workload of the heart. See sick hearts like to send out messages that say "Help! I'm weak! I need to beat faster! I need more resistance!" Essentially trying to round up the sympathetic nervous system to manage the symptoms. The beta blockers prevent these messages from taking effect, in effect they prevent the sick heart having to work a lot harder by beating faster, stronger, against more resistance.

If patient was spaced at 60, he should be at 60. Period. If the pacer was not capturing and the dude's native HR was rolling around 45---The pacer may need interrogation.

[RunninOnCoffee]

Makes sense. And I am glad you said that about the pacer too. My gut was thinking it should not have allowed for him to drop that low, that it should have continued to pace, but I wasn't 100% sure. I was thinking an interrogation was warranted. All I could think was that it saw an atrial beat and attempt so it was waiting to see if it would take over. The brady periods would last for 5-7 seconds or so. I think I did mention an interrogation to the son. I did talk to both the patient and son about following up with the cardiologist.

Any guesses on the amlodipine?

[Been there,done that, ASN, RN]

Amlodipine reduces vascular resistance, increase blood supply to the heart.

To attempt to analyze why the patient is on these meds, is not the point.

The point is the doctor you work for was NOT fully versed of his history . The administration of cardiac medications needed to be evaluated before the procedure.

His conduction system fires at 45 -50, for whatever reason. If his pacer kicked in and brought him up to 60 BPM.. no problem.

He has a demand pacemaker.

[Esme12, ASN, BSN, RN]

There are many reasons for a combination of cardiac meds. Pre-load/after load reduction where the cardiac benefit of the drugs outweigh any risks. Many patients waiting heart transplants are on strong cardiac meds with blood pressures low enough that they would be held on a "normal" patient but are necessary for them to keep them out of failure.

It is difficult to say about the pacer. It depends on what kind of pacer. Were they atrially paced as well? Was the monitor not really reading the pacer rhythm well? There are many variables.

It is not uncommon for a invasive radiologist to not explain questions like this as they are radiologists.

[exp626]

Based on the meds and AICD, I'm guessing he has heart failure. Assuming this is true, while both of those drugs slow the heart rate, that's not why they're given in this case, and a decrease in HR is just a side effect. Since he has a pacer we don't have to worry about the side effect of bradycardia...but this intrinsic rate of 45 is concerning, as the previous poster mentioned. In the setting of HF, there are multiple drugs that are prescribed as a gold standard, and beta blockers and calcium channel blockers are two of them (they both decrease afterload). He may take other meds, such as a diuretic (to decrease preload) and ACE inhibitor or ARB (to decrease afterload).

[TiffyRN, BSN, PhD]

I've been in NICU for, oh, I don't know, like a decade but I remember some cardiac stuff. Coreg (I think it was still brand name only when I was in cardiac) is a beta-blocker that is particularly useful in heart failure. I think there's a good chance your patient who has a pacer/defibrillator has some heart failure. Carvedilol specifically improves left ventricular ejection fraction.

I know it's an old article but here something. . .

Carvedilol: The New Role of Beta-Blockers in Congestive Heart Failure - American Family Physician