MEDizzy - A 58-year-old former professional badminton champion

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Cardinal Manifestations and Presentation of Diseases 2

A 58-year-old former professional badminton champion presents to your clinic for evaluation of palpitations. Unfortunately, since his badminton career ended 25 years ago, he has not kept up his physical ftness. As his primary care provider, you have been trying to manage his hypertension, hyperlipidemia, tobacco abuse, and lack of physical exercise. Two weeks ago, he decided to take your advice and start jogging to increase his aerobic exercise. However, at your clinic visit with him today, he notes that every time he starts to jog, he senses palpitations, feels very short of breath, and feels like he is going to pass out. Once, he thinks he may have lost consciousness briefy after sitting at the side of the jogging track. These sensations last for several minutes after he stops to rest. What is the most appropriate response to this patient?

ExplanationWhile the frst sentence of option B is a correct statement for the general population—most patients with palpitations do not have serious arrhythmias or structural heart disease—this patient has some features that are concerning that the palpitations may be due to a life-threatening etiology. The association of palpitations with syncope or presyncope is concerning for a ventricular arrhythmia (either idiopathic or ischemic in origin) or another tachyarrhythmia in a patient with structural heart disease. In this patient with multiple coronary risk factors, the onset of dyspnea and palpitations leading to presyncope/syncope during physical exertion is concerning for myocardial ischemia. Further evaluation with an exercise stress test is appropriate. The suggestion of swimming (option C) would be potentially very dangerous as he runs the risk of passing out while in the water. Counseling tobacco cessation is always correct (option D), although the red-fag symptoms of syncope and dyspnea with his palpitations warrant further workup. Holter monitoring (option E) can be useful for a patient who has frequent arrhythmias, but this patient reliably has his palpitations with exertion, not at rest.