What is the next step in managing a 65-year-old male presenting to the Emergency Department (ED) with heart palpitations and no previous medical history?

From the Guidelines

The next step in management for a 65-year-old male presenting to the ED with heart palpitations and no previous medical history should be a focused assessment including vital signs, a 12-lead ECG, and basic laboratory tests. Obtain vital signs to assess for hemodynamic stability, looking for hypotension, tachycardia, or irregular rhythm. A 12-lead ECG is essential to identify the specific arrhythmia causing the palpitations, such as atrial fibrillation, supraventricular tachycardia, or premature ventricular contractions, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1. Basic laboratory tests should include electrolytes (particularly potassium, magnesium, and calcium), complete blood count, thyroid function tests, and cardiac biomarkers to rule out myocardial injury.

Some key points to consider in the management of this patient include:

• The importance of a thorough clinical history and physical examination to define the presence and nature of symptoms associated with the arrhythmia, as well as any underlying heart disease or other reversible conditions 1
• The use of a 12-lead ECG to verify the arrhythmia and identify any underlying cardiac conditions, such as left ventricular hypertrophy or prior myocardial infarction 1
• The need for additional testing, such as continuous cardiac monitoring, chest X-ray, and possibly an echocardiogram, to assess cardiac structure and function and guide treatment decisions
• The consideration of rate control medications, such as beta-blockers or calcium channel blockers, for stable patients, and the potential need for immediate cardioversion in unstable patients with signs of compromised perfusion 1

Overall, the management of this patient should prioritize a systematic diagnostic approach to identify the underlying cause of the palpitations and guide treatment decisions, with a focus on minimizing morbidity, mortality, and improving quality of life.

From the Research

Next Steps in Managing a 65-Year-Old Male with Heart Palpitations

The next step in managing a 65-year-old male presenting to the Emergency Department (ED) with heart palpitations and no previous medical history involves:

• Taking a comprehensive patient history, as outlined in studies 2 and 3, to gather relevant information and inform diagnosis and treatment.
• Conducting a physical examination, as emphasized in studies 4 and 5, to help narrow down or establish a diagnosis.
• Using the patient history and physical as a basis for selecting relevant diagnostic testing, as supported by study 5, to lead to a timely and accurate diagnosis.

Importance of History Taking and Physical Examination

Key points to consider:

• A significant proportion of diagnoses are made based on history taking, often alongside physical assessments and laboratory investigations, as noted in study 3.
• Important communication skills for nurses when history taking include active listening, empathetic communication, and cultural sensitivity, as discussed in study 3.
• The physical examination remains an important component of patient evaluation, even in settings where imaging and laboratory tests are easily available, as stated in study 4.

Diagnostic Testing and Patient Evaluation

Considerations for diagnostic testing and patient evaluation:

• Beta-blockade may be considered in patients with coronary artery disease, as studied in 6, to enhance heart rate variability and potentially contribute to protective effects in ischemic heart disease.
• The patient history and physical should guide the selection of diagnostic testing to protect patients from unnecessary risks and ensure cost-effectiveness, as supported by study 5.