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MODULE 22: THE HOSPITAL ECOSYSTEM
Section 2.2: The Telemetry (“Tele”) Unit: The Cardiac Watchdogs
Step into the world of continuous cardiac monitoring, where your pharmacological vigilance as the “QTc Guardian” and antiarrhythmic expert is critical to patient safety.
SECTION 2.2
The Telemetry (“Tele”) Unit: The Cardiac Watchdogs
The critical need for continuous cardiac monitoring.
2.2.1 The “Why”: The Critical Need for Continuous Cardiac Monitoring
The Telemetry unit represents a significant step-up in care intensity from the standard Med-Surg floor. While patients here may not be critically ill enough to require an ICU, they have a known or suspected cardiac condition that makes them vulnerable to sudden, dangerous heart rhythm disturbances (arrhythmias). The core principle of a telemetry unit is proactive surveillance. Every patient is connected to a portable heart monitor that transmits their continuous electrocardiogram (ECG or EKG) to a central station, where skilled technicians and nurses watch for any deviation from a normal rhythm, 24/7.
This constant electrical surveillance is the “Why” of telemetry. It allows the clinical team to detect a potentially life-threatening arrhythmia the second it begins, long before it would cause overt symptoms. It is an early warning system that provides the crucial window of opportunity to intervene pharmacologically and prevent a patient from deteriorating. This environment is fundamentally different from retail pharmacy, where you manage the long-term consequences of cardiac disease. On the telemetry floor, you are on the front lines, managing the electrical instability of the heart in real-time, and your medication decisions have immediate, observable consequences on the ECG tracing.
A Pharmacist’s Guide to the EKG: What You Actually Need to Know
You do not need to be an electrophysiologist, but you must understand the basic EKG components to appreciate the impact of medications. Think of it as the electrical “vital signs” of the heart.
- P Wave: Represents the contraction of the atria (the top chambers). In atrial fibrillation, this is replaced by a chaotic, fibrillatory baseline.
- QRS Complex: Represents the powerful contraction of the ventricles (the main pumping chambers). This is the “pulse.” A normal QRS is narrow and sharp. A wide QRS can indicate a dangerous ventricular arrhythmia.
- T Wave: Represents the electrical “reset” or repolarization of the ventricles.
- QT Interval: This is the crucial one for pharmacists. It measures the total time from the start of the QRS complex to the end of the T wave. It represents the entire duration of ventricular activity. A longer-than-normal QT interval signals a delay in repolarization, which dramatically increases the risk for a life-threatening arrhythmia called Torsades de Pointes.
Common Reasons for Admission to Telemetry
Understanding why patients are on the unit helps you anticipate the types of medication problems you will be solving.
| Reason for Admission | The Underlying Cardiac Risk | Anticipated Pharmacist Role |
|---|---|---|
| Atrial Fibrillation with RVR | An uncontrolled, rapid heart rate (>100 bpm) can compromise cardiac output, causing symptoms like shortness of breath and dizziness. There is also a high risk of stroke. | Recommending IV rate control agents (metoprolol, diltiazem), ensuring appropriate anticoagulation is initiated based on stroke risk (CHA₂DS₂-VASc score). |
| Acute Coronary Syndrome (ACS) / Post-MI | Ischemic or damaged heart muscle is electrically unstable and prone to ventricular arrhythmias like ventricular tachycardia (VT) or ventricular fibrillation (VF). | Ensuring patient is on appropriate guideline-directed medical therapy (aspirin, P2Y12 inhibitor, beta-blocker, statin, ACEi/ARB). Monitoring for bradycardia from beta-blockers. |
| Syncope (Passing Out) | The cause is unknown, and it could be a dangerous arrhythmia (either too fast or too slow, like heart block) that caused the patient to lose consciousness. | Performing a thorough medication review to identify any drugs that could cause bradycardia (beta-blockers, diltiazem, verapamil, digoxin) or QTc prolongation. |
| Acute Decompensated Heart Failure (ADHF) | Fluid overload and electrolyte shifts (especially low potassium and magnesium from aggressive diuresis) can provoke arrhythmias. | Proactively monitoring and recommending repletion of potassium and magnesium. Dosing IV diuretics. Optimizing oral heart failure regimen prior to discharge. |
| Monitoring for Drug-Induced Arrhythmia | A patient is being started on a known proarrhythmic drug (e.g., sotalol, dofetilide) and requires a mandatory period of inpatient monitoring to ensure it is safe. | This is a pharmacist-led service. You will be responsible for verifying the appropriateness of the drug, ensuring baseline QTc is safe, and performing serial QTc checks after each dose. |
2.2.2 The Pharmacist’s Role: The QTc Guardian and Antiarrhythmic Expert
On the telemetry unit, your expertise is focused and sharp. You are the guardian of the QT interval and the specialist who guides the use of high-risk antiarrhythmic medications. This role requires constant vigilance, a deep understanding of pharmacology, and proactive communication with the medical and nursing teams.
Mastery 1: The QTc Guardian
The prolongation of the QT interval is one of the most common, and preventable, causes of serious medication-related adverse events in the hospital. The fatal arrhythmia it can trigger, Torsades de Pointes (TdP), is notoriously difficult to treat. Prevention is everything, and the pharmacist is the key prevention specialist. Your job is to identify patients at risk, screen their medication profiles for offending agents, and mitigate that risk through monitoring, electrolyte management, and recommending safer alternatives.
Defining the Danger: QTc Thresholds
The QT interval must be corrected for heart rate (this is the “c” in QTc). The computer does this for you, but you need to know what the numbers mean.
- Normal QTc: < 440 ms in men, < 460 ms in women
- Borderline QTc: 440-470 ms (men), 460-480 ms (women) – Use QTc-prolonging drugs with caution.
- Prolonged QTc: > 470 ms (men), > 480 ms (women) – High risk. Avoid QTc-prolonging drugs if possible.
- High-Risk Threshold: A QTc > 500 ms, or an increase of > 60 ms from baseline, is considered a major red flag for TdP.
The Usual Suspects: Common Drugs You MUST Know
You already dispense these medications every day. Now, you must view them through the lens of a telemetry pharmacist. The risk is magnified when these drugs are given IV, to acutely ill patients, and in combination.
| Drug Class | Common Offenders | Typical Hospital Scenario & Your Intervention |
|---|---|---|
| Antipsychotics | Haloperidol (IV), Quetiapine, Ziprasidone, Olanzapine | An agitated patient receives IV haloperidol. Your Role: Check a baseline EKG. If QTc is > 500ms, recommend an alternative like a benzodiazepine. Advocate for the lowest effective dose. |
| Antidepressants | Citalopram, Escitalopram, Tricyclics (e.g., Amitriptyline) | A patient on citalopram 40mg at home is admitted. Your Role: Flag the dose. FDA recommends a max of 20mg/day in patients > 60 years old. Recommend dose reduction. |
| Antibiotics | Fluoroquinolones (Levo-, Moxi-), Macrolides (Azithromycin) | Patient with pneumonia is started on both IV azithromycin and IV levofloxacin. Your Role: This is a “double hit.” Recommend discontinuing one agent and choosing an alternative with a better safety profile (e.g., ceftriaxone + doxycycline). |
| Antiemetics | Ondansetron (especially IV) | A post-op patient is receiving scheduled IV ondansetron 8mg Q8H. Your Role: This is an unnecessarily high and frequent dose for prophylaxis. Recommend switching to PRN dosing or a non-QTc prolonging alternative if possible. |
| Antiarrhythmics | Amiodarone, Sotalol, Dofetilide, Procainamide | These are known offenders and the reason for telemetry monitoring. Your Role: Scrutinize every other medication on the profile to eliminate any additional QTc-prolonging agents. Ensure electrolytes are aggressively managed. |
| Others | Methadone | A patient on methadone for opioid use disorder is admitted. Your Role: Recognize that methadone is a significant QTc prolonger. Ensure a baseline EKG is performed and that no other offending drugs are added. |
The Trifecta of Risk: Your Daily Screening Checklist
Every morning, for every patient on your telemetry service, you should be asking these three questions:
- What is today’s QTc? Is it > 500 ms or has it increased by > 60 ms?
- What are the morning labs? Is the Potassium < 4.0 mEq/L or the Magnesium < 2.0 mg/dL? If so, recommend IV repletion immediately.
- Is the patient on ONE or MORE QTc-prolonging medications? If so, is there a safer alternative for any of them?
If you find a patient with a QTc > 500ms, low electrolytes, AND is on multiple offending drugs, you have found a ticking time bomb. This requires an urgent call to the primary team.
Mastery 2: The Antiarrhythmic Expert
While QTc monitoring is a defensive game, managing antiarrhythmics is pure offense. You are actively using high-risk drugs to terminate arrhythmias and restore normal sinus rhythm. The most common scenario you will face is atrial fibrillation with a rapid ventricular response (RVR).
Masterclass: Pharmacologic Management of Atrial Fibrillation with RVR
The Goal: The immediate goal is NOT to convert the patient back to normal rhythm. The immediate goal is rate control: to slow down the ventricular response to a safe level (typically a heart rate < 100 bpm) to improve cardiac output and alleviate symptoms.
Step 1: Choose Your Rate Control Agent
The first-line choice is almost always an IV beta-blocker or a non-dihydropyridine calcium channel blocker.
| Agent | Mechanism | Typical IV Dosing | When to Choose This Agent | When to AVOID This Agent (Contraindications) |
|---|---|---|---|---|
| Metoprolol Tartrate | Beta-1 selective blocker. Slows AV nodal conduction. | IV Push: 5 mg IV over 2 minutes, may repeat up to 3 doses (total 15 mg). Transition to PO: Start oral dose 15-30 mins after last IV dose. (e.g., 25-50 mg PO BID) |
The workhorse. A safe, general-purpose choice, especially in patients post-MI or those with stable heart failure. | Decompensated heart failure (e.g., “wet” with fluid overload), severe bradycardia, hypotension (SBP < 100), severe asthma/COPD (relative). |
| Diltiazem | Non-DHP CCB. Potent effect on slowing AV nodal conduction. | IV Push: 0.25 mg/kg (actual body weight) over 2 mins. May give 2nd bolus of 0.35 mg/kg. IV Drip: Start infusion at 5-10 mg/hr, titrate to goal HR (max 15 mg/hr). |
Often works faster and is more effective than metoprolol. Excellent choice for patients with preserved heart function and reactive airway disease. | Absolute Contraindication: Heart Failure with Reduced Ejection Fraction (HFrEF, EF < 40%) due to negative inotropic effects. Also avoid in hypotension. |
Retail Pharmacist Analogy: The Overwhelmed Cashier
Imagine it’s the busiest day of the year. You have one cashier (the AV Node) and a hundred customers (atrial impulses) trying to check out at once. The cashier is overwhelmed, trying to serve everyone, and the checkout line (the ventricular rate or pulse) is chaotic and dangerously fast. This is AFib with RVR.
Your goal is not to get rid of the customers. Your goal is to control the chaos. You can send a manager (Metoprolol) to stand with the cashier and force them to slow down, taking one customer at a time in an orderly fashion. Or, you can call in the district manager (Diltiazem), who is even more effective at enforcing a slower, more deliberate pace.
But if the store’s foundation is shaky (Heart Failure with Reduced Ejection Fraction), bringing in the heavy-handed district manager (Diltiazem) could be too much stress and cause the whole system to collapse. In that specific situation, the gentler local manager (Metoprolol) is the only safe choice. As the pharmacist, you are the one who knows the store’s condition and can recommend the right manager for the job.
Step 2: Initiate Anticoagulation for Stroke Prevention
Once the rate is controlled, you must address stroke risk. Atrial fibrillation causes blood to pool and clot in the atria. These clots can travel to the brain and cause a devastating ischemic stroke. Your role is to calculate the patient’s stroke risk using the CHA₂DS₂-VASc score and recommend appropriate anticoagulation.
| Risk Factor | Points |
|---|---|
| C – Congestive Heart Failure | 1 |
| H – Hypertension | 1 |
| A₂ – Age ≥ 75 years | 2 |
| D – Diabetes Mellitus | 1 |
| S₂ – Stroke/TIA/Thromboembolism (prior) | 2 |
| V – Vascular Disease (prior MI, PAD) | 1 |
| A – Age 65-74 years | 1 |
| Sc – Sex category (Female) | 1 |
Interpreting the Score and Making a Recommendation:
- Score = 0 (males) or 1 (females): Low risk. Anticoagulation is not recommended.
- Score ≥ 1 (males) or ≥ 2 (females): Anticoagulation is recommended. The preferred agents are the Direct Oral Anticoagulants (DOACs) over warfarin.
Your Recommendation: “This patient has a history of hypertension and is 76 years old, giving him a CHA₂DS₂-VASc score of 3. Guideline-directed therapy to reduce his high risk of stroke is an oral anticoagulant. I recommend starting apixaban 5 mg PO BID.”
