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 cardiovascular risk factors, optimization of blood pressure and diabetes control, and further cardiac assessment to identify potential causes of her symptoms, including consideration of extended cardiac monitoring and referral to a cardiologist. The patient's presentation of dizziness, presyncope, and possible brief syncope, in the context of her history of hypertension and diabetes, necessitates a thorough approach to rule out significant cardiac or neurological causes.

Key Components of Management:

• Optimization of blood pressure control, aiming for a target of <140/90 mmHg, while being cautious of excessive diastolic lowering that could potentially worsen her symptoms 1.
• Given her normal echocardiogram with preserved ejection fraction, no specific heart failure therapy is indicated at this time.
• For secondary prevention, initiating antiplatelet therapy (aspirin 81mg daily) and a moderate-intensity statin (atorvastatin 20mg daily) for cardiovascular risk reduction is recommended 1.
• Diabetes management should be optimized with a target HbA1c of <7.5%, considering her age and comorbidities 1.
• The first-degree AV block and LBBB on ECG, along with the episode of non-sustained wide complex tachycardia on Holter monitoring, warrant further evaluation by a cardiologist, including consideration of extended cardiac monitoring (30-day event monitor) to detect potential arrhythmias causing her symptoms 1.
• Checking orthostatic vital signs to rule out orthostatic hypotension and reviewing medications to identify any potential contributors to her dizziness or syncope are also crucial steps.
• The presence of bundle branch block on ECG, as seen in this patient, is a predictor for abnormal conduction properties identified at EPS, but the underlying cause for syncope may be related to vasodepressor mechanisms rather than heart block mediated bradycardia 1. Given the complexity of her presentation and the need for specialized care, referral to a cardiologist for further evaluation and management is strongly recommended.

From the FDA Drug Label

The FDA drug label does not answer the question.

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.

Medical Management

• According to the study by 2, patients with peripheral vascular disease should be treated aggressively with a combination of a HMG CoA reductase inhibitor, an angiotensin-converting enzyme (ACE) inhibitor, an antiplatelet agent, and a beta blocker if there is a history of coronary disease.
• The study by 3 suggests that the combination of beta-blockers and ACE inhibitors is beneficial in patients with cardiovascular disease, including those with hypertension and diabetes.
• The study by 4 recommends that patients with diabetes should be started on an ACE inhibitor or angiotensin II receptor blocker (ARB) to manage hypertension and prevent end-organ damage.
• The study by 5 found that ACE inhibitors and ARBs have similar effects on total mortality and cardiovascular events, but ARBs may have a slightly lower incidence of withdrawals due to adverse effects.
• The study by 6 suggests that ACE inhibitors and ARBs may be beneficial in preventing the new onset of type 2 diabetes mellitus.

Treatment Recommendations

• Based on the evidence, the patient should be started on an ACE inhibitor or ARB to manage hypertension and prevent end-organ damage 4.
• A beta blocker may also be considered to manage hypertension and prevent cardiovascular events 3.
• A statin should be prescribed to manage hyperlipidemia and prevent cardiovascular events 2.
• The patient should also receive tight control of blood pressure and blood sugar, and should be encouraged to stop smoking and maintain a healthy lifestyle 2.