What is the workup for a 47-year-old male with undiagnosed hypertension (HTN), hyperlipidemia (hld), not yet on medications, complaining of palpitations and bradycardia?

From the Guidelines

For a 47-year-old male with undiagnosed hypertension, hyperlipidemia, and complaints of heart flutters and low heart rate, I strongly recommend starting with a 12-lead ECG to assess heart rhythm and rate, as this is a crucial initial step in the routine work-up for all patients with hypertension, especially when presenting with cardiac symptoms like irregular pulse or heart flutters, as emphasized in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.

Initial Assessment

The patient's symptoms of heart flutters and low heart rate necessitate a thorough cardiovascular evaluation.

• A 12-lead ECG is essential to analyze for left ventricular hypertrophy (LVH) and atrial fibrillation (AF), as these conditions are closely associated with hypertension and can significantly impact morbidity, mortality, and quality of life.
• Given the patient's complaints, it is also crucial to consider the potential for cardiac arrhythmias, which are often seen in patients with hypertension, as discussed in the European Heart Journal's consensus document on hypertension and cardiac arrhythmias 1.

Comprehensive Workup

Beyond the initial ECG, a comprehensive workup should include:

• 24-hour Holter monitoring to capture intermittent arrhythmias, which may not be evident on a standard ECG.
• Comprehensive blood tests, including electrolytes, thyroid function, and lipid panel, to identify any underlying conditions that could be contributing to the patient's symptoms.
• An echocardiogram to evaluate cardiac structure and function, which is recommended in patients with hypertension when the ECG is abnormal, murmurs are detected, or there are cardiac symptoms, as per the 2024 ESC guidelines 1.
• Blood pressure monitoring with multiple readings over several visits to confirm the diagnosis of hypertension.
• Fasting blood glucose testing to rule out diabetes, which often coexists with hypertension and hyperlipidemia.

Lifestyle Modifications

While awaiting diagnosis, lifestyle modifications are crucial:

• Reducing sodium intake to less than 2300mg daily.
• Adopting the DASH diet.
• Exercising moderately for 150 minutes weekly.
• Limiting alcohol.
• Avoiding tobacco.
• Maintaining a healthy weight. These modifications can help reduce cardiovascular risk and prevent long-term complications like heart disease and stroke.

Considerations

The combination of uncontrolled hypertension and hyperlipidemia significantly increases cardiovascular risk. Addressing these conditions early can prevent long-term complications. The patient's symptoms warrant prompt evaluation, as they could indicate various conditions from benign palpitations to more serious arrhythmias. The 2024 ESC guidelines and the consensus document on hypertension and cardiac arrhythmias provide a framework for the management of patients with hypertension and suspected arrhythmias, emphasizing the importance of a comprehensive workup and timely intervention to improve outcomes 1.

From the Research

Undiagnosed Hypertension and Heart Symptoms

• A 47-year-old male with undiagnosed hypertension and a history of heart disease, not yet on medication, is complaining of heart flutters and low heart rate.
• According to 2, echocardiography can provide clues suggesting a bad prognosis associated with hypertension, including increased left ventricular mass, decreased left ventricular systolic function, impaired left ventricular diastolic function, and increased left atrial size and decreased function.

Diagnosis and Evaluation of Hypertension

• The diagnosis of hypertension and precise assessment of cardiovascular risk are essential to give proper treatment in patients with hypertension 2.
• Blood pressure screening using an office-based measurement is recommended for adults 18 years and older without a history of hypertension, and if abnormal, the BP measurement should be repeated twice with the average of those final two readings used to determine the BP category 3.
• Home BP monitoring and ambulatory BP monitoring are beneficial in patients for whom there is a concern for masked or white-coat hypertension 3.

Management of Hypertension

• Lifestyle modifications are the foundation of hypertension management, with the Dietary Approaches to Stop Hypertension (DASH) diet being the most effective dietary modification 3, 4.
• First-line pharmacotherapy should include one or more of the following: an angiotensin-converting enzyme inhibitor, an angiotensin receptor blocker, a dihydropyridine calcium channel blocker, and a thiazide or thiazide-like diuretic 3, 4.
• Valsartan, a new angiotensin II antagonist, has been shown to have similar antihypertensive efficacy to lisinopril, an angiotensin-converting enzyme inhibitor, and appears to be associated with a reduced incidence of cough 5.

Cardiovascular Risk Assessment

• Echocardiographic measures of structure and function carry prognostic information in patients with hypertension, and the development of a consensus position on the use of echocardiography in this setting is important 6.
• The assessment of adults with hypertension should focus on identifying complications of the condition and comorbid cardiovascular risk factors 4.