Evaluation of Intermittent Hypertension, Palpitations, and Exertional Dyspnea
A Holter monitor and echocardiogram are excellent initial diagnostic tests for evaluating intermittent hypertension, palpitations, exertional dyspnea, and a briefly elevated BNP that has since normalized. 1
Rationale for Diagnostic Approach
- Echocardiography is clearly indicated in patients with cardiac symptoms like dyspnea, especially when coexisting with abnormalities such as palpitations and hypertension 2
- Holter monitoring is appropriate for evaluating palpitations and suspected arrhythmias, particularly when atrial fibrillation is suspected 1
- The combination of these symptoms with a previously elevated BNP warrants comprehensive cardiac evaluation to rule out structural and functional cardiac abnormalities 1
Value of Echocardiography
Key Parameters to Assess:
- Left ventricular systolic function (ejection fraction) to rule out systolic heart failure 1
- Diastolic function parameters, as approximately one-third of patients with cardiac dyspnea have abnormalities in left ventricular diastolic function 2, 3
- Left ventricular hypertrophy assessment, which may be present in patients with hypertension 1, 2
- Valvular structure and function to exclude valvular heart disease 1
- Estimation of pulmonary pressures via tricuspid regurgitation velocity 1, 2
Clinical Relevance:
- Echocardiography can identify the cause of exertional dyspnea when heart failure is suspected but the contribution is uncertain (Class IIa recommendation) 1
- Provides essential information about structural abnormalities that may explain the constellation of symptoms 1
- Can detect diastolic dysfunction, which is more common in patients with hypertension and can cause exertional dyspnea despite normal ejection fraction 2, 3
Value of Holter Monitoring
- Helps detect intermittent arrhythmias that may explain palpitations 1
- Can identify atrial fibrillation, which may be paroxysmal and not captured on standard ECG 1
- Provides correlation between symptoms (palpitations, dyspnea) and cardiac rhythm disturbances 4
- May reveal tachyarrhythmias that could explain both palpitations and intermittent hypertension 1
Significance of BNP Fluctuations
- BNP can be transiently elevated during episodes of increased cardiac stress and normalize between episodes 1, 5
- Even with normal systolic function, elevated BNP can indicate diastolic dysfunction 3, 6
- BNP levels increase during exercise in patients with suspected diastolic heart failure and correlate with exercise-induced elevation of filling pressures 7
- Transient BNP elevation may predict future cardiovascular events even when it normalizes 6
Additional Considerations
- If initial testing is inconclusive, consider exercise stress testing with measurement of respiratory gas exchange to determine if heart failure is causing exercise limitation 1
- Evaluate for other causes of exertional dyspnea and palpitations, such as thyroid dysfunction, which can present with similar symptoms and cause pulmonary hypertension 8
- Consider ambulatory blood pressure monitoring if intermittent hypertension is a prominent feature 1
Clinical Pitfalls to Avoid
- Don't rely solely on normalized BNP to exclude cardiac pathology, as BNP levels can fluctuate and may be normal between symptomatic episodes 5, 6
- Avoid attributing symptoms to anxiety without thorough cardiac evaluation, especially with the combination of palpitations, dyspnea, and intermittent hypertension 1
- Don't overlook diastolic dysfunction as a cause of exertional dyspnea in patients with normal ejection fraction 2, 3
- Remember that BNP levels may be falsely low in patients with obesity despite significant cardiac pathology 1