You push the IV metoprolol. His HR improves to the 100s. You're happy with this, as you know that this is a good target considering he's acutely ill. You then start enteral metoprolol 12.5mg q6h. You also give IV magnesium 2g. You repeat a non-contrast head CT, which shows only a small infarct burden. You thus feel comfortable initiating heparin gtt at this early time point given a thorough risk/benefit analysis.
Over the next few days, you rapidly uptitrate the enteral metoprolol, but he continues to go intermittently into RVR, now sometimes into the 170s. (He's never hemodynamically unstable, fortunately.) You add digoxin, but that still doesn't end up helping. Ultimately, because of all this trouble, and because you know he's therapeutically anticoagulated now, you start him on amiodarone. This works.
He works with PT, OT, and SLP, and is deemed a candidate for inpatient rehab. He is discharged there on day 10 of admission, with close neurology and cardiology follow-up arranged.
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