From the Guidelines
For a 73-year-old female with increasing fatigue requiring cardiac workup, I recommend a comprehensive evaluation starting with a detailed history and physical examination, followed by basic laboratory tests including complete blood count, comprehensive metabolic panel, thyroid function tests, and B-type natriuretic peptide (BNP) as outlined in the American College of Cardiology/American Heart Association guidelines 1. This approach is crucial because fatigue in elderly patients can have multiple etiologies, including cardiac origins such as heart failure, coronary artery disease, valvular disease, or arrhythmias, as well as non-cardiac causes like anemia, thyroid dysfunction, medication side effects, or depression. Given the patient's age and symptom of increasing fatigue, it's essential to consider age-related cardiovascular changes like increased arterial stiffness and decreased cardiac reserve, which can exacerbate fatigue with minimal exertion 1. The evaluation should also include an electrocardiogram (ECG) and echocardiogram to assess cardiac structure and function, as well as exercise stress testing or pharmacological stress testing with imaging to evaluate for coronary artery disease. Ambulatory ECG monitoring for 24-48 hours can detect arrhythmias, and if initial testing suggests significant coronary disease, referral for coronary angiography may be necessary. The patient should be asked about associated symptoms like chest pain, shortness of breath, palpitations, dizziness, and edema to guide the evaluation. It's also important to assess treatable contributing factors, including comorbidities, medications, alcohol/substance abuse, nutritional issues, and deconditioning, as outlined in the American Society of Clinical Oncology clinical practice guideline adaptation 1. Referral to an appropriately trained professional, such as a cardiologist, may be necessary based on the findings of the initial evaluation. Key considerations in the management of fatigue in elderly patients include a comprehensive assessment, identification of treatable causes, and a multidisciplinary approach to care. By prioritizing a thorough evaluation and considering the broad range of potential causes of fatigue, healthcare providers can optimize the management of this symptom and improve patient outcomes.
From the Research
Cardiac Workup for Fatigue in a 73-Year-Old Female
- Fatigue is a common complaint in patients with cardiovascular disease and can be the first clinical manifestation of the disease 2.
- The diagnostic approach for fatigue in cardiovascular disease is designed to eliminate other organic causes of fatigue and may include functional tests to investigate physical and mental dimensions 2.
- In patients with suspected cardiovascular disease, stress testing can be used to diagnose and assess the severity of the disease 3.
- The choice of stress test depends on the individual patient and may include standard treadmill exercise testing, myocardial perfusion imaging, radionuclide angiography, stress echocardiography, or cardiopulmonary exercise testing 3.
- In older individuals with chronic illnesses, fatigue is a common symptom that can negatively impact quality of life and is associated with comorbidities, depression, and anxiety 4.
- Management strategies for fatigue in older individuals with chronic illnesses may include physical activity, rest, sleep, maintaining normal hemoglobin levels, and acetyl-l-carnitine supplementation 4.
- Acute heart failure can present with symptoms of fatigue, dyspnea, and orthopnea, and diagnosis in the emergency department may involve electrocardiogram, complete blood count, basic metabolic profile, liver function tests, troponin, brain natriuretic peptide, and a chest radiograph 5.
- Point-of-care ultrasound can be a useful modality in diagnosing heart failure by assessing for B-lines, cardiac function, and inferior vena cava size 5.