How should I evaluate and manage an adult six months after sepsis who has persistent tachycardia, fluctuating blood pressure from severe hypertension to mild elevation, and associated fatigue, dizziness, and nausea?

Post-Sepsis Cardiovascular Dysautonomia: Evaluation and Management

This presentation 6 months after sepsis represents post-sepsis syndrome with persistent autonomic dysfunction, requiring systematic cardiovascular evaluation to exclude structural cardiac damage, endocrine abnormalities, and residual infection before attributing symptoms to dysautonomia.

Immediate Diagnostic Workup

Cardiac Evaluation

• Obtain transthoracic echocardiography to assess for septic cardiomyopathy, which can persist months after sepsis and is characterized by biventricular impairment with reduced left ventricular ejection fraction and stroke work index 1
• Measure high-sensitivity troponin levels, as myocardial dysfunction commonly occurs in sepsis and troponin elevation correlates with cardiac dysfunction severity 1
• Perform 24-hour ambulatory blood pressure monitoring to characterize the hypertensive episodes and identify patterns, as sepsis-related hypertensive responses can occur with renal salt wasting and glomerular hyperfiltration 2
• Order 12-lead ECG and consider Holter monitoring to evaluate tachycardia etiology and exclude arrhythmias that may require specific management 3

Endocrine and Metabolic Assessment

• Check thyroid function (TSH, free T4) to exclude hyperthyroidism as a cause of persistent tachycardia and blood pressure fluctuations
• Measure morning cortisol and consider ACTH stimulation test if adrenal insufficiency is suspected, as sepsis can cause lasting hypothalamic-pituitary-adrenal axis dysfunction
• Assess for pheochromocytoma with plasma metanephrines if hypertensive episodes are paroxysmal with associated symptoms

Exclusion of Ongoing Infection

• Obtain complete blood count, C-reactive protein, and procalcitonin to exclude smoldering infection or inflammatory process
• Consider imaging of the original sepsis source to ensure complete resolution

Management Strategy

Blood Pressure Management

If echocardiography reveals preserved ejection fraction with hypertensive episodes:

• Initiate angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers as first-line therapy, as these agents are associated with significantly lower 90-day mortality in sepsis patients compared to other antihypertensives (odds ratio 1.27 for non-users; 95% CI, 1.07-1.52) 4
• Avoid calcium channel blockers as monotherapy despite their association with reduced inotropic agent requirements, as they do not provide the same survival benefit as ACE inhibitors/ARBs 4

If echocardiography reveals reduced ejection fraction (septic cardiomyopathy):

• Continue chronic beta-blockers if previously prescribed, as they should be maintained in the absence of acute hemodynamic decompensation or cardiogenic shock 3
• Add ACE inhibitors/ARBs for dual benefit of blood pressure control and cardiac remodeling prevention 4
• Avoid aggressive fluid resuscitation for blood pressure fluctuations, as traditional fluid targets do not increase adverse events in heart failure patients but should be guided by clinical assessment 3

Tachycardia Management

For persistent sinus tachycardia without heart failure:

• Consider beta-blocker therapy after hemodynamic stabilization, as beta-blockers have shown independent benefits in sepsis and are appropriate for rate control 3
• Target heart rate <90 bpm based on sepsis diagnostic criteria, though individualize based on symptoms 5

For atrial fibrillation with rapid ventricular response:

• Use intravenous beta-blockers (esmolol or metoprolol) with extreme caution if no overt congestion or hypotension is present 6
• Consider digoxin if beta-blockers are contraindicated due to reduced ejection fraction 6

Symptomatic Management

For fatigue, dizziness, and nausea:

• Ensure adequate hydration status with assessment of orthostatic vital signs and urine output
• Monitor for signs of tissue hypoperfusion including decreased capillary refill, skin mottling, peripheral cyanosis, and oliguria (urine output <0.5 mL/kg/h) 5
• Avoid vasopressor therapy unless mean arterial pressure drops below 65 mmHg with signs of tissue hypoperfusion 5

Critical Pitfalls to Avoid

• Do not attribute all symptoms to post-sepsis syndrome without excluding structural cardiac damage, as septic cardiomyopathy with biventricular dysfunction is common and requires specific management 1
• Never use dopamine for blood pressure support if vasopressors become necessary, as it is associated with higher mortality and more arrhythmias compared to norepinephrine 6, 7
• Avoid aggressive fluid boluses without hemodynamic assessment, as patients may have occult cardiac dysfunction requiring cautious volume management 3
• Do not discontinue chronic antihypertensive medications abruptly during blood pressure fluctuations, particularly ACE inhibitors/ARBs which provide mortality benefit 4

Monitoring Parameters

• Serial echocardiography every 3-6 months if initial study shows dysfunction, as septic cardiomyopathy can improve over time 1
• Regular assessment of blood pressure, heart rate, and symptoms with 24-hour ambulatory monitoring if fluctuations persist 2
• Lactate levels if hypotension develops, as this indicates tissue hypoperfusion requiring urgent intervention 5
• Renal function monitoring given the association between sepsis-related hypertension and glomerular hyperfiltration 2