What is the best course of treatment for a patient with palpitations, hay fever symptoms, asthma, severe anxiety, and a history of smoking, with an ECG showing sinus bradycardia and tall T waves in chest leads?

Management of Palpitations and Anxiety in a Patient with Asthma

The most appropriate treatment for this patient is to address the severe anxiety (GAD-7 score of 19) as the primary cause of palpitations, while also treating the hay fever symptoms and ensuring proper asthma management.

Assessment of Palpitations

Clinical Evaluation

• ECG shows sinus bradycardia (49 bpm) with tall T waves in chest leads V3-V6
• Palpitations are worse when lying down and after smoking cigarettes
• Associated chest discomfort and difficulty breathing fully
• No wheeze heard on examination
• Vital signs: BP 144/80, HR 76, O2 saturation 99%

Differential Diagnosis

1. Anxiety-induced palpitations (GAD-7 score of 19 indicates severe anxiety)
2. Sinus bradycardia (possibly vagally-mediated)
3. Smoking-related symptoms
4. Allergic rhinitis (hay fever)
5. Underlying asthma contribution

Management Plan

1. Address Anxiety

• Start with a beta-blocker such as metoprolol 25-50 mg PO BID for both anxiety and palpitation management 1
• Beta-blockers can help reduce the physical symptoms of anxiety including palpitations
• Monitor for potential worsening of asthma symptoms, though metoprolol is relatively beta-1 selective 2
• Consider psychiatric referral for cognitive behavioral therapy for severe anxiety

2. Hay Fever Management

• Prescribe a second-generation antihistamine (e.g., loratadine 10 mg daily or cetirizine 10 mg daily)
• Add intranasal corticosteroid (e.g., fluticasone nasal spray) for nasal congestion
• Avoid sedating antihistamines which may worsen bradycardia

3. Asthma Management

• Ensure proper use of current medications (Breo Ellipta and salbutamol)
• Educate on proper inhaler technique
• Consider smoking cessation counseling as smoking exacerbates both asthma and anxiety

4. Cardiac Evaluation

• Obtain an echocardiogram to exclude structural heart disease 3, 4
• Consider ambulatory ECG monitoring (Holter monitor for 24-48 hours) to correlate symptoms with cardiac rhythm 3, 5
• If palpitations persist despite treatment, extended monitoring with an event recorder may be warranted 1

Special Considerations

Sinus Bradycardia

• Sinus bradycardia at 49 bpm requires monitoring but may not need specific treatment if asymptomatic 3
• The bradycardia may be vagally-mediated, particularly if worse when lying down
• Ensure no medications are contributing to bradycardia

Smoking Cessation

• Strongly recommend smoking cessation as it:
  • Exacerbates asthma symptoms
  • Can trigger palpitations
  • Worsens anxiety in the long term
  • Increases cardiovascular risk

Follow-up Plan

• Schedule follow-up in 2 weeks to assess response to treatment
• Monitor for any worsening of asthma with beta-blocker therapy
• Adjust medication doses as needed based on symptom response

Common Pitfalls to Avoid

• Don't attribute all symptoms to anxiety without appropriate cardiac evaluation
• Don't overlook the potential interaction between beta-blockers and asthma; use cardioselective agents and monitor closely 2
• Don't miss the opportunity to address smoking cessation as a key intervention
• Don't ignore sinus bradycardia completely; monitor for symptomatic bradycardia
• Don't forget to evaluate for other causes of tall T waves (electrolyte abnormalities, ischemia)

By addressing the patient's anxiety as the likely primary cause of palpitations while also managing hay fever symptoms and optimizing asthma control, this comprehensive approach should lead to symptom improvement and better quality of life.