What is the best course of action for a 52-year-old male with a persistent cough, on lisinopril, with a history of heavy alcohol intake and smoking, who experienced syncope (loss of consciousness) twice after coughing, with possible atrial enlargement and normal sinus rhythm (NSR) on electrocardiogram (EKG)?

Immediate Management of Syncope with Cough-Induced Loss of Consciousness

This patient requires urgent cardiac evaluation with hospital admission given multiple high-risk features: age >50 years, syncope during cough (Valsalva-like maneuver), possible atrial enlargement on ECG, and significant cardiac risk factors including smoking, heavy alcohol use, and lisinopril therapy suggesting underlying hypertension. 1, 2

Critical High-Risk Features Present

This patient demonstrates several concerning characteristics that mandate aggressive evaluation:

• Age 52 years with male sex - both independent predictors of cardiac syncope and increased mortality risk 1
• Possible atrial enlargement on ECG - abnormal ECG findings are Class I indicators for cardiac evaluation 1, 2
• Syncope during cough - while cough syncope can be situational/reflex, in middle-aged patients with cardiac risk factors and ECG abnormalities, arrhythmia must be excluded first 2, 3
• Heavy alcohol intake and smoking - both increase risk of structural heart disease and arrhythmias 1
• On lisinopril - indicates underlying hypertension/cardiovascular disease, which has 95% sensitivity for cardiac syncope 2

Immediate Diagnostic Workup Required

Priority Testing (Class I Recommendations)

Echocardiography should be performed urgently to assess for:

• Structural heart disease given possible atrial enlargement 1, 2
• Left ventricular function and hypertrophy 1, 2
• Valvular abnormalities 1

48-hour continuous ECG monitoring (Holter or telemetry) is essential to detect:

• Paroxysmal arrhythmias including atrial fibrillation, given atrial enlargement 1, 2
• Bradyarrhythmias or conduction abnormalities 1
• Ventricular arrhythmias 1, 2

Targeted laboratory testing should include:

• Electrolytes, BUN, creatinine - to assess for medication effects and renal function 2
• BNP and high-sensitivity troponin - to evaluate for heart failure or ischemia 2
• Consider alcohol level and liver function tests given heavy alcohol intake 1

Address the Persistent Cough

Evaluate and treat the underlying cough as this is both a trigger and potentially related to cardiac disease:

• Consider ACE inhibitor-induced cough from lisinopril - occurs in 5-35% of patients 1
• Assess for heart failure as cause of cough (orthopnea, paroxysmal nocturnal dyspnea) 1, 2
• Rule out pulmonary pathology in this heavy smoker 1

Critical Management Decisions

Do NOT Assume Benign Cough Syncope

The combination of age, cardiac risk factors, and ECG abnormalities overrides the situational trigger. 2, 3 The 2017 ACC/AHA guidelines explicitly state that elderly patients on vasoactive drugs with cardiac history require thorough cardiac evaluation despite situational triggers. 2

Medication Review is Essential

Polypharmacy assessment:

• Lisinopril can cause both cough and orthostatic hypotension 2
• Heavy alcohol intake potentiates hypotensive effects 1
• Consider switching from ACE inhibitor to ARB if cough is medication-related 2

Orthostatic vital signs must be measured (supine, then at 1 and 3 minutes standing) - a drop in systolic BP ≥20 mmHg or to <90 mmHg indicates orthostatic hypotension requiring medication adjustment 2, 3

Risk Stratification Mandates Admission

This patient meets multiple criteria for hospital admission: 1, 2

• Age >60 years (52 is approaching this threshold with multiple risk factors)
• Known cardiovascular disease (hypertension requiring treatment)
• Abnormal ECG (possible atrial enlargement)
• Recurrent syncope (twice in one night)
• Male sex

Subsequent Evaluation Based on Initial Findings

If Echocardiogram Shows Structural Disease

Electrophysiological study may be indicated if:

• Significant left ventricular hypertrophy or dysfunction is present 1
• Conduction abnormalities are identified 1
• Syncope remains unexplained after non-invasive testing 1

If Initial Cardiac Workup is Negative

Consider implantable loop recorder for:

• Recurrent unexplained syncope despite negative initial evaluation 1, 2, 3
• Superior diagnostic yield (52% vs 20%) compared to conventional testing 3

Common Pitfalls to Avoid

Do not dismiss this as simple vasovagal or cough syncope based on the trigger alone - age and comorbidities demand thorough cardiac evaluation 2, 3

Do not rely on a single normal ECG - if clinical suspicion remains high, prolonged monitoring with loop recorders is essential 3

Do not perform carotid sinus massage given the possible atrial enlargement and need to rule out cerebrovascular disease first 2

Do not discharge without addressing the persistent cough - this may be the key to preventing recurrence and could indicate underlying cardiac or pulmonary pathology 1, 2

Disposition and Follow-up

Hospital admission is recommended for continuous monitoring, echocardiography, and risk stratification 1, 2. Outpatient management is inappropriate given the high-risk features present. 1, 2

Alcohol cessation counseling and smoking cessation must be initiated as both significantly increase cardiovascular risk and mortality 1