Make the Diagnosis: Dizziness Dilemma

Presentation

Case Findings: The patient is a 42-year-old African American man who presents with a complaint of dizziness lightheadedness which occurred when he was standing up to go to the rest room 3 days ago. He denies any previous syncopal episodes. He has medically managed hypertension, hypercholesterolemia, cardiomyopathy with last ejection fraction of 35% with defibrillator placement 4 months previous. His ICD did not fire during the episode. His last cardiac catheterization prior to ICD implantation revealed normal coronaries. Patient has been compliant with metoprolol 25 mg twice daily, lisinopril 10 mg daily, atorvastatin 40 mg daily. He denies any new medical regimen. His vital signs are BP 100/80 mm Hg and HR 66/min. His physical examination is normal without any clinical evidence of decompensation. ECG is shown below.

What is the next best course of action?

Learnings

Correct Answer:

C - Continue with the current medical regimen. This is a patient with clinical presentation consistent with orthostatic hypotension. The best course of action is to obtain orthostatics on the patient. Current physical examination and vital signs are stable. ECG shown reveals left ventricular hypertrophy with repolarization changes. There are no acute new changes to suggest any emergent intervention. Current evidence supports the use of ACE inhibitors and (to a lower level of evidence) beta­blocker therapy to impede maladaptive LV remodeling in patients with LV dysfunction to improve mortality and morbidity. ARBs are reasonable alternatives to ACE inhibitors. In patients with previously established structural heart disease, the administration of agents known to have negative inotropic properties such as nondihydropyridine calcium channel blockers and certain antiarrhythmics should be avoided. Target levels of blood pressure lowering depend on major cardiovascular risk factors, (e.g., CAD, diabetes mellitus, or renal disease). Diuretic­based antihypertensive therapy has been shown to prevent HF in a wide range of target populations. In refractory hypertensive patients, spironolactone (25 mg) should be considered as an additional agent. Eplerenone, in synergy with enalapril, has also demonstrated reduction in LV mass. In this particular case, given patient is well compensated and with dizziness on standing up, no additional diuretics or hypertensive agents are recommended.

---

Let's block ads! (Why?)

Make the Diagnosis: Dizziness Dilemma