Make the Diagnosis: Dizziness Dilemma

Presentation

Case Findings: A 42-year-old African American male presents with a report of dizziness and lightheadedness 3 days ago when he was standing up to go to the rest room. He denies any syncopal episodes. He has medically managed hypertension, hypercholesterolemia, and cardiomyopathy, and a last ejection fraction of 35% with defibrillator placement 4 months ago. His AICD did not fire during the dizziness episode. His last cardiac catheterization prior to AICD implantation revealed normal coronaries. The 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.

What is best course of action based on what the ECG suggests?

Learnings

Correct Answer:

C. Continue current medical regimen. Obtain blood pressure and heart rate sitting and standing. This clinical presentation is 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) beta-blocker therapy to impede maladaptive LV remodeling in patients with LV dysfunction to reduce 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, (CAD, diabetes mellitus, or renal disease). Diuretic-based antihypertensive therapy has been shown to prevent heart failure 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, no additional diuretics or hypertensive agents are recommended.

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Make the Diagnosis: Dizziness Dilemma