What is the best course of management for an 80-year-old female with a history of hypertension and diabetes, presenting with an episode of dizziness, presyncope, and brief syncope, with hypotension, bradycardia, first-degree atrioventricular (AV) block, left bundle branch block (LBBB), and non-sustained wide complex tachycardia (WCT)?

From the Guidelines

The patient should undergo a comprehensive evaluation and management plan focusing on her cardiac, neurological, and metabolic conditions, with a priority on optimizing blood pressure, managing diabetes, and addressing potential cardiac conduction issues. Given her clinical presentation of dizziness, presyncope, and possible brief syncope, along with a history of hypertension and diabetes, it is crucial to consider the management of her blood pressure and diabetes in the context of her overall health and quality of life. The evidence from 1 and 1 suggests that blood pressure management should aim for target values of 130-139/70-79 mmHg, considering her age and comorbidities. The first-degree AV block and LBBB on ECG, along with the episode of non-sustained wide complex tachycardia on Holter monitoring, as discussed in 1 and 1, warrant referral to a cardiologist for consideration of permanent pacemaker implantation. Antiplatelet therapy with aspirin 81mg daily is recommended given her diffuse carotid atherosclerosis, as generally advised for patients with atherosclerotic disease. Diabetes management should be continued with a target HbA1c of 7.0-8.0%, using medications with low hypoglycemia risk, as suggested by guidelines including those referenced in 1. The patient should also undergo vestibular function testing to evaluate for peripheral causes of dizziness and fall risk assessment and prevention strategies are essential, including home safety evaluation and physical therapy for balance training. This approach is supported by the most recent guidelines and evidence, prioritizing her morbidity, mortality, and quality of life outcomes. Key considerations include:

• Optimizing blood pressure control
• Managing diabetes with a focus on minimizing hypoglycemia risk
• Evaluating and managing cardiac conduction abnormalities
• Preventing further vascular events with antiplatelet therapy
• Addressing potential neurological causes of her symptoms
• Improving her overall quality of life through comprehensive care.

From the Research

Management of Hypertension and Diabetes in an 80-Year-Old Female

• The patient has a history of hypertension and diabetes, and has experienced an episode of dizziness and presyncope, with a blood pressure of 127/54 mmHg and a pulse of 69 beats per minute 2.
• The electrocardiogram (ECG) shows sinus rhythm, first-degree AV block, and left bundle branch block (LBBB), while the echocardiogram shows normal ejection fraction (EF) and valvular calcifications without significant stenosis 2.
• The patient has hemodynamically non-significant diffuse atherosclerotic carotid disease on both sides, with the left vertebral artery not well evaluated 2.
• The Holter monitor shows infrequent premature atrial contractions (PACs) and premature ventricular contractions (PVCs), with one episode of non-sustained wide complex tachycardia (WCT) 2.

Treatment Options

• According to the study by 3, the combination of metformin and antihypertensive therapy with drugs blocking the renin-angiotensin system may be a cause of concern, as it can increase the risk of metformin-associated lactic acidosis.
• The study by 4 suggests that ACE inhibitors, beta-blockers, calcium blockers, and diuretics can be effective in controlling systolic hypertension, with calcium blockers and diuretics being more effective in elderly patients.
• The study by 5 shows that initial combination therapy with an ACE inhibitor and a calcium channel blocker achieves superior blood pressure control compared to calcium channel blocker monotherapy in patients with stage 2 hypertension.
• The study by 6 introduces a multifaceted approach to the management of diabetes mellitus in resource-limited settings, which may be applicable to this patient's case.

Considerations

• The patient's blood pressure is currently well-controlled, but the presence of diabetes and hypertension requires careful management to prevent cardiovascular and renal complications 2.
• The patient's ECG and echocardiogram results suggest that she may be at risk for cardiac complications, and therefore requires close monitoring and management of her cardiovascular risk factors 2.
• The patient's carotid disease and vertebral artery disease may also require further evaluation and management to prevent stroke and other cardiovascular complications 2.