What is the best course of action for a patient with well-controlled asthma on Breo (fluticasone furoate and vilanterol) and Ventolin (albuterol), who experiences exercise-induced palpitations with lightheadedness, and has a history of hay fever (allergic rhinitis)?

Management of Exercise-Induced Palpitations in a Patient with Well-Controlled Asthma

Continue the current asthma regimen (Breo and Ventolin PRN) without modification, as the asthma is well-controlled, and initiate a cardiac workup for the exercise-induced palpitations, which are unrelated to the asthma therapy and require evaluation to exclude arrhythmia before attributing them to benign causes.

Asthma Management Assessment

Current Control Status

• This patient meets all criteria for well-controlled asthma based on the absence of symptoms, no nighttime awakenings, minimal rescue inhaler use, no activity interference, and normal examination findings 1.
• Well-controlled asthma is defined as symptoms ≤2 days/week, nighttime awakenings ≤2 times/month, short-acting β-agonist use ≤2 days/week, no interference with normal activity, and FEV1 or peak flow >80% predicted 1.
• When asthma is well-controlled, the treatment should remain unchanged rather than stepping up or down therapy 1.

Prescription Renewal

• Renew both Breo (fluticasone furoate/vilanterol) and Ventolin (albuterol) prescriptions as the current regimen is achieving optimal control 1.
• Breo represents a Step 3 therapy (low-to-medium dose ICS plus LABA), which is appropriate for this level of control 1.
• The combination of fluticasone furoate/vilanterol has demonstrated excellent safety and tolerability over 52 weeks with no clinically significant adverse cardiac effects beyond expected mild increases in pulse rate 2.

Addressing Allergic Rhinitis

• Consider adding a leukotriene receptor antagonist (montelukast 10 mg once daily) for the hay fever, as this can address both allergic rhinitis symptoms and provide additional asthma control 1, 3.
• Montelukast is taken once daily, has high compliance rates, and is particularly beneficial for patients with allergic components 1, 3.
• However, counsel the patient about the black box warning for neuropsychiatric events (agitation, depression, sleep disturbances, suicidal thoughts) and instruct them to report any mood or behavioral changes immediately 4.

Palpitations Evaluation

Distinguishing Cardiac from Medication-Related Causes

• These palpitations are unlikely to be caused by the current asthma medications for several reasons:
  • The patient has been on Breo (which contains the LABA vilanterol) without prior palpitation complaints
  • Palpitations only occur during exercise, not at rest or after medication administration
  • The timing (started late in the specified date) does not correlate with medication initiation
  • Associated lightheadedness suggests a more significant cardiac issue than simple β-agonist stimulation 5

Cardiac Workup Required

• Obtain a 12-lead ECG immediately to evaluate for baseline conduction abnormalities, pre-excitation syndromes, or QT prolongation 5.
• Order a 24-hour Holter monitor or event monitor to capture the palpitations during exercise and characterize the rhythm disturbance 5.
• Check thyroid function tests (TSH, free T4) as the patient denies heat intolerance and weight loss, but thyroid dysfunction can present with isolated palpitations 1.
• Consider an exercise stress test if Holter monitoring does not capture events, as this can provoke the arrhythmia in a monitored setting 5.

Risk Stratification

• The presence of lightheadedness with palpitations elevates concern for hemodynamically significant arrhythmia rather than benign premature contractions 5.
• The brief duration (20 seconds) and cessation with activity termination could represent paroxysmal supraventricular tachycardia (PSVT), which is common in young adults 5.
• Response to breath-holding/box breathing (vagal maneuvers) further supports PSVT as a likely diagnosis 5.

Critical Pitfalls to Avoid

Do Not Attribute Palpitations to Asthma Medications Prematurely

• Avoid discontinuing or reducing the LABA component of Breo, as this would compromise well-achieved asthma control 1.
• LABAs should never be discontinued without maintaining ICS therapy, and in this case, the asthma control would likely deteriorate 1.
• The FDA drug label for fluticasone furoate/vilanterol notes dose-dependent increases in heart rate (mean 7.8 bpm at therapeutic doses), but these are immediate post-dose effects, not exercise-induced phenomena occurring hours later 5.

Do Not Overlook Comorbid Conditions

• Evaluate for gastroesophageal reflux disease (GERD), as this can exacerbate both asthma and cause palpitations, though the patient denies chest pain 1.
• Assess for anxiety or panic disorder, though the strict exercise association and absence of sweating, tremors, or hyperventilation make this less likely 1.
• Confirm no use of β-blockers or NSAIDs, which can worsen asthma control, though this patient's asthma is currently well-controlled 1.

Do Not Delay Cardiac Evaluation

• The combination of palpitations with lightheadedness during exercise requires prompt evaluation to exclude life-threatening arrhythmias 5.
• While the patient has not experienced syncope, the lightheadedness severe enough to stop activity warrants urgent rather than routine cardiology assessment 5.

Management Algorithm

1. Today's visit actions:

   • Renew Breo and Ventolin prescriptions 1
   • Obtain 12-lead ECG in office 5
   • Order Holter monitor or event monitor 5
   • Order TSH, free T4 1
   • Consider adding montelukast 10 mg daily for rhinitis with appropriate counseling 3, 4

2. If ECG shows abnormalities or Holter captures significant arrhythmia:

   • Refer to cardiology urgently 5
   • Consider exercise restriction pending cardiology evaluation 5

3. If cardiac workup is normal:

   • Reassure patient about benign nature 5
   • Continue current asthma regimen 1
   • Follow up in 3 months to reassess asthma control 1

4. Ongoing asthma monitoring:

   • Schedule follow-up in 3 months to assess continued control 1
   • Educate patient that well-controlled asthma should have symptoms ≤2 days/week and rescue inhaler use ≤2 days/week 1
   • Provide written asthma action plan 1