What is the best course of action for a 69-year-old female with a history of Coronary Artery Disease (CAD) presenting with anxiety and palpitations for 2 days, normal vitals, and an electrocardiogram (ECG) showing Premature Ventricular Contractions (PVCs) and sinus bradycardia?

Management of 69-Year-Old Female with CAD, Anxiety, Palpitations, PVCs, and Sinus Bradycardia in Urgent Care

This patient requires immediate transfer to the emergency department for comprehensive cardiac evaluation, as her history of CAD combined with new palpitations and ECG abnormalities (PVCs with sinus bradycardia) necessitates urgent assessment for acute coronary syndrome and risk stratification that cannot be adequately performed in an urgent care setting. 1

Immediate Actions in Urgent Care (Before Transfer)

Critical Assessment Within 10 Minutes

• Obtain vital signs including oxygen saturation and assess hemodynamic stability (blood pressure, heart rate, respiratory rate) to identify hypotension, tachypnea, or signs of heart failure 1
• Perform focused cardiovascular examination looking specifically for diaphoresis, new murmurs (particularly mitral regurgitation), S3 gallop, pulmonary rales, jugular venous distention, or peripheral edema—all indicators of acute decompensation 1, 2
• Assess chest pain characteristics including exact location, radiation pattern (especially to left arm/jaw), quality (pressure vs sharp), duration, and associated symptoms like dyspnea, nausea, or diaphoresis 1, 3

Pre-Transfer Interventions

• Administer aspirin 162-325 mg (chewed, not swallowed) immediately unless contraindicated by active gastrointestinal bleeding or known allergy 1, 3
• Establish continuous cardiac monitoring to detect ventricular arrhythmias or progression to more malignant rhythms 1
• Arrange emergency medical services transport rather than private vehicle, as complications may occur en route requiring immediate intervention 1, 3

Why Emergency Department Transfer is Mandatory

High-Risk Features Present

• History of CAD places her at elevated risk for acute coronary syndrome, where PVCs may represent myocardial ischemia or herald more serious ventricular arrhythmias 1
• New-onset palpitations lasting 2 days in a patient with established coronary disease requires exclusion of unstable angina/NSTEMI, as symptoms may represent acute ischemia 1
• Combination of PVCs with sinus bradycardia creates concern for underlying conduction system disease, electrolyte abnormalities, or medication effects that require comprehensive evaluation 1

Required Testing Beyond Urgent Care Capabilities

• Serial high-sensitivity cardiac troponin measurements at presentation and 2-3 hours later to detect myocardial injury with >90% sensitivity and >95% specificity 1, 3
• 24-48 hour ambulatory Holter monitoring to quantify PVC burden (>2,000 PVCs/24 hours associated with 30% prevalence of structural heart disease) and assess for non-sustained ventricular tachycardia 1, 2
• Echocardiography to evaluate for new wall motion abnormalities, valvular disease, or left ventricular dysfunction that may explain symptoms 1, 2
• Exercise stress testing or coronary imaging if troponins negative, to assess for inducible ischemia and determine if PVCs suppress or increase with exertion 1, 2

Risk Stratification Framework

Intermediate-to-High Risk Indicators

• Age 69 years with established CAD automatically places her in intermediate risk category for adverse cardiovascular events 1
• Anxiety may represent anginal equivalent, particularly in women who often present with atypical symptoms including emotional distress, fatigue, and dyspnea rather than classic chest pain 3
• PVCs in setting of CAD warrant investigation for active ischemia, as ventricular ectopy can be triggered by myocardial oxygen supply-demand mismatch 1, 2

Potentially Reversible Causes to Communicate

• Electrolyte abnormalities (hypokalemia, hypomagnesemia) should be assessed in ED as they commonly precipitate ventricular ectopy 2
• Heightened adrenergic tone from anxiety may contribute to both palpitations and PVCs, but this remains a diagnosis of exclusion after ACS ruled out 2
• Medication review needed to identify QT-prolonging drugs or recent changes that might explain arrhythmias 1, 2

Common Pitfalls to Avoid

Do NOT Delay Transfer For:

• Attempting to obtain troponin in urgent care setting—this delays definitive care and serial measurements are required for adequate sensitivity 3
• Administering nitroglycerin as diagnostic test—response does not distinguish cardiac from non-cardiac causes (esophageal spasm also responds) 3
• Reassuring patient based on "normal vitals"—hemodynamic stability does not exclude ACS, and 10-25% of ACS patients present with non-characteristic symptoms 1

Critical Errors in Assessment

• Assuming anxiety explains all symptoms—in patients with CAD, new anxiety may represent anginal equivalent or presage acute event 4
• Dismissing isolated PVCs as benign—in context of known structural heart disease, even simple PVCs warrant comprehensive evaluation for underlying ischemia or progression of disease 1, 5
• Treating sinus bradycardia with atropine without clear indication—bradycardia with normal blood pressure requires no treatment; atropine doses >2.5 mg cumulative increase risk of ventricular tachycardia/fibrillation 1, 6

Communication with Emergency Department

Essential Information to Relay

• Complete medication list including beta-blockers, calcium channel blockers, antiarrhythmics, and any recent changes 1
• Exact timing of symptom onset (2 days ago) to guide troponin interpretation and risk assessment 1
• ECG findings including heart rate, presence of ST-segment changes, T-wave abnormalities, or pathological Q waves suggesting prior infarction 1
• Response to aspirin administration and any contraindications encountered 3

The urgent care setting lacks the diagnostic capabilities and monitoring infrastructure required to safely evaluate this patient—immediate ED transfer with EMS transport is the only appropriate management. 1, 3