What is the appropriate work‑up and management for a 61‑year‑old man presenting for repeat prescription of Betaloc (metoprolol) 47.5 mg daily and atorvastatin 20 mg daily who had a brief (<1 minute) blackout while seated a week ago, now reports chest heaviness/burning worse when supine, intermittent burping and bloating, dry throat and cough, and has a blood pressure of 152/78 mmHg?

Immediate Work-Up and Management for Syncope with Chest Symptoms and Uncontrolled Hypertension

Urgent Cardiac Evaluation Required

This patient requires immediate ECG, troponin, and consideration of acute coronary syndrome given the combination of syncope, chest heaviness/burning when supine, and inadequately controlled hypertension on current beta-blocker therapy. 1

The constellation of symptoms—brief loss of consciousness while seated, chest heaviness worse when lying down, and blood pressure of 152/78 mmHg despite Betaloc 47.5 mg daily—demands urgent evaluation for cardiac ischemia before attributing symptoms to gastroesophageal reflux or other benign causes.

Priority Diagnostic Work-Up

Immediate Testing (Same Visit)

• 12-lead ECG to identify acute ischemia, conduction abnormalities (PR interval >0.24 seconds, second- or third-degree heart block), or arrhythmias that would contraindicate continued beta-blocker therapy 2, 1
• Troponin to rule out acute myocardial infarction, as chest heaviness with syncope raises concern for cardiac ischemia 2
• Basic metabolic panel including potassium and creatinine, given recent UTI treatment and to assess for electrolyte abnormalities that may contribute to arrhythmia 2
• Blood glucose to exclude hypoglycemia as a cause of syncope and altered consciousness 2

Additional Cardiac Assessment

• Echocardiogram to evaluate left ventricular function, wall motion abnormalities suggesting ischemia, and structural heart disease 2, 1
• 24-hour Holter monitor if initial ECG is non-diagnostic, to capture paroxysmal arrhythmias that may explain the blackout episode 1
• Exercise stress test (if troponin negative and ECG non-ischemic) to assess for exertional ischemia, given chest symptoms and inadequate blood pressure control 2

Blood Pressure Management Optimization

Current Regimen Assessment

• Betaloc (metoprolol) 47.5 mg once daily is subtherapeutic for both hypertension control (current BP 152/78 mmHg) and secondary prevention if coronary disease is present 1, 3
• The target blood pressure should be <130/80 mmHg, ideally achieving at least a 20/10 mmHg reduction from baseline 1
• Blood pressure readings show significant variability (181/100,140/60, now 152/78), suggesting inadequate 24-hour control with current dosing 1

Medication Titration Strategy

• Increase metoprolol succinate to 100 mg once daily (or metoprolol tartrate 50 mg twice daily) after cardiac work-up excludes contraindications 1, 3
• Verify absence of contraindications before uptitration: no signs of heart failure (chest is clear, no peripheral edema documented), heart rate adequate, no high-grade AV block on ECG 2, 1
• Titrate every 1-2 weeks based on blood pressure and heart rate response, with target dose of 200 mg daily for optimal cardiovascular protection 1, 3
• Add ACE inhibitor or ARB if blood pressure remains >130/80 mmHg after beta-blocker optimization, as combination therapy is more effective than monotherapy 2

Critical Contraindications to Verify

• Do not increase metoprolol if ECG shows PR interval >0.24 seconds, second- or third-degree heart block, or if patient develops signs of heart failure 2, 1
• Hold beta-blocker if systolic blood pressure drops <100 mmHg with symptoms or heart rate falls <50 bpm with dizziness 1
• Current examination shows no contraindications (chest clear, no peripheral edema, blood pressure 152/78), but these must be reassessed after each dose increase 2, 1

Evaluation of Chest Symptoms

Distinguish Cardiac from Gastrointestinal Causes

• Chest heaviness/burning worse when supine with burping suggests GERD, but this presentation overlaps significantly with cardiac ischemia, especially in a patient with cardiovascular risk factors on statin therapy 2
• Red flags favoring cardiac etiology: syncope preceding chest symptoms, association with exertion (though patient reports symptoms at rest and when lying down), male sex, age 61, hypertension, on statin (suggesting dyslipidemia) 2
• Features suggesting GERD: worse when lying down, associated burping and bloating, no sour taste (though absence doesn't exclude reflux), dry throat 2

Management Approach

• Treat empirically for GERD only after cardiac causes are excluded with negative troponin, non-ischemic ECG, and normal stress test if performed 2
• Consider proton pump inhibitor (omeprazole 20 mg daily) for 4-8 weeks if cardiac work-up is negative 2
• Do not attribute chest symptoms to GERD without cardiac evaluation in a patient with syncope and uncontrolled hypertension 2

Syncope Evaluation

Characterization of the Event

• Brief (<1 minute) loss of consciousness while seated without fall, no tongue biting, no incontinence, no abnormal movements—suggests cardiac syncope rather than seizure 1
• Prodrome of dizziness and fatigue supports vasovagal or cardiac cause 1
• Absence of neurological deficits on examination (cranial nerves intact, normal limb examination) makes stroke less likely 1

Cardiac Syncope Work-Up

• Orthostatic vital signs to assess for orthostatic hypotension, which can be exacerbated by beta-blockers 1
• Carotid sinus massage (if no carotid bruits) to evaluate for carotid sinus hypersensitivity 1
• Tilt-table test if initial cardiac work-up is negative and syncope remains unexplained 1

Metoprolol-Related Considerations

• Beta-blockers can cause symptomatic bradycardia and syncope, especially if heart rate drops <50 bpm 1
• Current dose of 47.5 mg daily is relatively low, making beta-blocker-induced syncope less likely, but must verify heart rate was not severely bradycardic during the event 1
• CNS side effects of metoprolol (confusion, fatigue, dizziness, sleep disturbance) are well-documented, particularly in elderly patients, and may contribute to near-syncope 4

Additional Symptoms Requiring Attention

Neck Tightness

• One week of neck tightness preceding syncope raises concern for carotid or vertebrobasilar insufficiency 1
• Carotid duplex ultrasound to assess for significant stenosis if cardiac work-up is negative 1
• Neck tightness worse in afternoon/evening may also represent muscle tension, but vascular causes must be excluded given syncope 1

Dry Throat, Dry Cough, Sensation of Something Stuck

• ACE inhibitor should be considered as alternative to increasing beta-blocker alone, but dry cough is a common side effect of ACE inhibitors 2
• Current symptoms may represent viral upper respiratory infection or post-infectious cough 2
• Angiotensin receptor blocker (ARB) preferred over ACE inhibitor if cough persists, as ARBs do not cause cough 2

Monitoring and Follow-Up

Short-Term (1-2 Weeks)

• Recheck blood pressure and heart rate after any medication adjustment 1
• Assess for recurrent syncope, chest symptoms, or worsening fatigue that may indicate medication intolerance 1
• Review cardiac work-up results and adjust management based on findings 2, 1

Long-Term (Every 1-3 Months)

• Titrate antihypertensive therapy to achieve target blood pressure <130/80 mmHg 1
• Monitor for beta-blocker CNS side effects (confusion, nightmares, sleep disturbance, gait problems) particularly in this 61-year-old patient 4
• Continue statin therapy (atorvastatin 20 mg daily) for cardiovascular risk reduction 2

Common Pitfalls to Avoid

• Do not attribute chest symptoms to GERD without excluding acute coronary syndrome in a patient with syncope and cardiovascular risk factors 2
• Do not increase beta-blocker dose without first obtaining ECG to rule out conduction abnormalities that would contraindicate uptitration 2, 1
• Do not abruptly discontinue metoprolol if side effects occur; taper by 25-50% every 1-2 weeks to prevent rebound hypertension or angina 1
• Do not rely on single blood pressure reading; the variability in this patient's readings (181/100,140/60,152/78) suggests need for home blood pressure monitoring or 24-hour ambulatory monitoring 1
• Do not overlook metoprolol CNS side effects (fatigue, dizziness, confusion) as contributing to syncope, especially in older patients 4