Is it appropriate to admit a 70-year-old female patient with a history of hypertension and sinus tachycardia to a Physical Medicine and Rehabilitation (PM&R) hospital with no access to laboratory services or specialist consultation?

Admission Decision for 70-Year-Old Female with Sinus Tachycardia to PM&R-Only Facility

This patient should NOT be admitted to a PM&R-only hospital without laboratory and specialist access until a complete workup for secondary causes of sinus tachycardia has been performed. 1, 2

Critical Rationale

The fundamental principle in managing sinus tachycardia is that the underlying cause must be identified before any treatment or disposition decision is made. 1, 2 Sinus tachycardia at a resting heart rate of 120-127 bpm in a 70-year-old patient with hypertension represents a significant clinical finding that demands systematic evaluation for potentially serious underlying pathology. 1, 2

Why This Patient Requires Full Diagnostic Capability

• Sinus tachycardia is defined as a heart rate >100 bpm that occurs in response to physiological, pathological, or pharmacological stress—it is not a primary diagnosis but a symptom of an underlying condition. 1

• In elderly patients, persistent sinus tachycardia at rest (120-127 bpm) without an obvious physiological trigger mandates evaluation for life-threatening causes including pulmonary embolism, anemia, infection with sepsis, hyperthyroidism, heart failure, acute coronary syndrome, and hypovolemia. 1, 2

• The American College of Cardiology specifically recommends systematic evaluation for pathological causes including fever, hypovolemia, anemia, hypotension/shock, pain, heart failure, hyperthyroidism, and pheochromocytoma in hemodynamically stable patients with sinus tachycardia. 2

Essential Workup Requirements

Before any disposition decision, this patient requires:

• Complete blood count to evaluate for anemia 1, 2
• Comprehensive metabolic panel to assess renal function, electrolytes, and glucose 1, 2
• Thyroid function tests (TSH, free T4) to exclude hyperthyroidism 1, 2
• Troponin levels to rule out acute coronary syndrome 1
• Brain natriuretic peptide (BNP or NT-proBNP) if heart failure is suspected 1
• Chest radiograph to evaluate for pulmonary pathology or heart failure 1
• Assessment for infection including urinalysis and cultures if clinically indicated 1, 2
• Medication review for drugs causing tachycardia (caffeine, albuterol, aminophylline, atropine, catecholamines, stimulants) 1, 2

Age-Specific Considerations

• For a 70-year-old patient, the maximum expected sinus rate is approximately 150 bpm (220 minus age), making a resting rate of 120-127 bpm abnormally elevated and concerning. 3, 2

• In elderly patients with ventricular rates <150 bpm in the absence of ventricular dysfunction, the tachycardia is more likely secondary to an underlying condition rather than the cause of instability—but this underlying condition must be identified. 2

Hypertension as a Complicating Factor

• The patient's history of hypertension increases the likelihood of underlying cardiac disease, including heart failure, coronary artery disease, or left ventricular hypertrophy, all of which can present with or be complicated by sinus tachycardia. 1

• Resistant hypertension evaluation requires assessment for secondary causes including primary aldosteronism, renal artery stenosis, pheochromocytoma, and sleep apnea—several of which can also cause sinus tachycardia. 1

Critical Pitfalls to Avoid

The American Heart Association and American College of Cardiology explicitly warn against suppressing sinus tachycardia before identifying the underlying cause. 2 Admitting this patient to a facility without diagnostic capability would:

• Delay identification of potentially life-threatening conditions 1, 2
• Risk inappropriate rate control that could mask compensatory tachycardia (e.g., in heart failure, anemia, or sepsis) 2
• Prevent timely specialist consultation if secondary causes like hyperthyroidism, pheochromocytoma, or cardiac disease are identified 1, 2

Appropriate Disposition

This patient should first be evaluated in an acute care setting with full laboratory and imaging capabilities, access to cardiology consultation, and ability to perform comprehensive workup for secondary causes of sinus tachycardia. 1, 2

Only after excluding reversible and treatable causes of sinus tachycardia can the patient be safely transferred to a PM&R facility for rehabilitation. 1, 2 If inappropriate sinus tachycardia is ultimately diagnosed after excluding all secondary causes, then symptom-directed treatment with beta-blockers can be initiated and the patient may be appropriate for PM&R admission. 1, 3, 2