It's the sort of question that I wouldn't crowd-source!

Try Medscape for a start, but it seems to me that you have a clinical picture that needs to be evaluated carefully. What is the patient on? Why the bradycardia?? And it the hypertension treated or not???

I can't begin to answer this question, and I would be very suspicious of someone who did!

Dear Dr. Conroy,

Thanks for your reply. Yes, I agree with your point, so I only need expert advice.

The patient has a long h/o of hypertension, and on medications (beta-blockers), recently been diagnosed for DM for which he is taking metformin. H/o of several episodes of AF for which he was under close observation in the ICU. ECG findings were normal, except bradycadia. Thyroid hormone (T4) slightly elevated, but not a concern.

For recurrent episodes of AF, he has been on medications, but the cardiologists are differing on opinion about the need for implantation of a pacing device. Although a pacemaker wouldn't cure AF, I thought it may be a better option to treat underlying  bradycardia.  

Best Regards, Sidharta

Dear Dr. Conroy,

there seems to be conflicting evidences regarding the use of beta blockers in HTN to slow down heart rate. While some physicians are still advocating beta blocs post MI, others are against using it. I assume the reason the patient is having bradycardia while on antihypertensive medications (including a beta blocker) which may be precipitating AF.

My question is, Can beta blockers induce AF?

However, it may be a good idea to implant a pace maker which would likely correct bradycardia.

The patient is being treated by a specialist who is reluctant to use antihypertensive agents other than beta blocker. Is there any specific reasons for that? 

http://www.medscape.com/viewarticle/790281

Regards, Sidharta

With all respect, I suggest that you need to do a literature review. However, it looks like the jury is out on this one. Have you considered switching the antihypertensive. That might throw some light on its role.

I would no prefere ES. It necessary treat the patient medicamntously and treat art. hypertension. I wuld include antincoagulation therapy

There are so many variables here, and of course the setting is critically important in deciding what to do. Do you have access to AF ablation, for example, which would be another option, with a change in the antihypertensive Rx. But it all depends - how much bother with AF, how bad is the hypertension recently, is the brady all the time, is it worse immediately post AF (sick sinus). The management if intermittent/paroxysmal AF is v complex, with many options depending on the pts circumstances. I don't know of data to suggest BB produce AF. And, very important does the pt have symptoms due to the brady (which we assume is sinus but you haven't told us) or are you treating a number?

There is no indication of pacemaker for a patient with atrial fibrillation per se. At the age of 70 years, most likely it is lone AF. We have to think whether we are dealing a case of sick sinus syndrome. In that case pacemaker is the option. Another situation  may be the one where anti-arrhythmic treatment is indicated and pacemaker implantation  is necessary  before initiation of treatment.