Why are electrocardiogram (ECG) and respiratory assessment priority bedside evaluations for an 8-week post-surgical aortic valve replacement (SAVR) patient presenting with new onset palpitations, lightheadedness, and diaphoresis, with tachycardia and elevated blood pressure?

From the Guidelines

ECG and respiratory assessments are crucial priority bedside assessments for this patient due to his recent aortic valve replacement surgery and new onset symptoms of palpitations, light-headedness, and sweating. The patient's symptoms, particularly the palpitations and light-headedness, could be indicative of arrhythmias or conduction abnormalities, which are common complications after cardiac surgery, as highlighted in the Valve Academic Research Consortium 3 1. An ECG would be essential in identifying any abnormal heart rhythms, conduction disturbances, or signs of myocardial ischemia that might be causing his symptoms. The elevated heart rate of 104 beats/minute further necessitates cardiac monitoring to rule out post-surgical complications like atrial fibrillation. Respiratory assessment is also critical because his respiratory rate is elevated at 22 breaths/minute, suggesting potential respiratory distress despite normal oxygen saturation. This could indicate early heart failure, pulmonary complications, or anxiety related to his symptoms. The interconnection between cardiac and respiratory systems means that dysfunction in one often affects the other. Given the patient's recent discontinuation of warfarin, there's also a concern for potential thromboembolic events that could affect both cardiac and pulmonary function. The 2020 ACC expert consensus decision pathway on management of conduction disturbances in patients undergoing transcatheter aortic valve replacement 1 and the 2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement in the management of adults with aortic stenosis 1 support the importance of monitoring for conduction disturbances and arrhythmias post-cardiac surgery. These assessments would provide immediate, valuable information to guide further management of this post-cardiac surgery patient experiencing concerning symptoms, prioritizing his morbidity, mortality, and quality of life. Key points to consider include:

• The patient's recent aortic valve replacement surgery and the associated risks of cardiac complications
• The new onset symptoms of palpitations, light-headedness, and sweating, which could indicate arrhythmias or conduction abnormalities
• The importance of ECG in identifying abnormal heart rhythms or conduction disturbances
• The elevated respiratory rate suggesting potential respiratory distress
• The interconnection between cardiac and respiratory systems and the potential for thromboembolic events after discontinuing warfarin.

From the Research

Priority Bedside Assessments

The patient's presentation of new onset, episodic symptoms such as chest palpitations, light-headedness, and sweating, particularly in a non-exertional setting, warrants further investigation. Given the patient's history of surgical aortic valve replacement (SAVR) 8 weeks prior, it is essential to consider potential complications or related conditions that may be contributing to these symptoms.

ECG Assessment

• The patient's symptoms of palpitations and light-headedness, combined with an elevated heart rate (HR) of 104 beats/min, suggest the need for an electrocardiogram (ECG) assessment to evaluate for potential arrhythmias or other cardiac abnormalities 2.
• The study by 2 highlights the importance of prioritizing ECG assessments in patients presenting with symptoms that may indicate ST-elevation myocardial infarction (STEMI), even in the absence of chest pain.
• Given the patient's age and symptoms, an ECG assessment is crucial to rule out underlying cardiac conditions that may be contributing to their presentation.

Respiratory Assessment

• Although the patient's respiratory rate (RR) is elevated at 22 breaths/min, there are no signs of respiratory distress, and oxygen saturation (SpO2) is normal at 96% on room air 3.
• However, the patient's elevated RR and symptoms of light-headedness and sweating may indicate underlying respiratory or cardiac issues that require further evaluation.
• A comprehensive respiratory assessment, as outlined by 3, is essential to identify potential respiratory complications or conditions that may be contributing to the patient's symptoms.

Rationale for Priority Assessments

• The patient's history of SAVR and current symptoms suggest the need for prompt evaluation and management to prevent potential complications or deterioration.
• The studies by 4, 5, and 6 highlight the importance of considering atrial fibrillation (AF) and other cardiac conditions in patients undergoing aortic valve replacement, which may be relevant to this patient's presentation.
• By prioritizing ECG and respiratory assessments, the nurse can gather crucial information to inform further management and potential interventions to address the patient's symptoms and prevent adverse outcomes.