An 86-year-old woman is evaluated in the office for a 2-month history of lightheadedness with episodes of near-syncope and imbalance that last for seconds. She has had no syncope or falls. The patient lives in a personal care home and performs most of her daily activities with some assistance. Her medical problems include mild Alzheimer dementia, hypertension, coronary artery disease with coronary artery bypass grafting, and mitral valve repair 10 years ago. Her medications include aspirin, quinapril, amlodipine, simvastatin, and donepezil.
Her blood pressure is 162/82 mm Hg supine and 155/85 mm Hg standing. Her pulse is 50/min. Pulse oximetry is 96% on room air. She is alert and oriented to time and place. Cardiac examination shows a II/VI holosystolic murmur present at the apex. There are no carotid bruits. Lungs are clear to auscultation.
ECG shows sinus bradycardia and QRS complex duration of 98 msec.
Which of the following is the best next step in management of this patient?

Question

An 86-year-old woman is evaluated in the office for a 2-month history of lightheadedness with episodes of near-syncope and imbalance that last for seconds.  She has had no syncope or falls.  The patient lives in a personal care home and performs most of her daily activities with some assistance.  Her medical problems include mild Alzheimer dementia, hypertension, coronary artery disease with coronary artery bypass grafting, and mitral valve repair 10 years ago.  Her medications include aspirin, quinapril, amlodipine, simvastatin, and donepezil.
Her blood pressure is 162/82 mm Hg supine and 155/85 mm Hg standing.  Her pulse is 50/min.  Pulse oximetry is 96% on room air.  She is alert and oriented to time and place.  Cardiac examination shows a II/VI holosystolic murmur present at the apex.  There are no carotid bruits.  Lungs are clear to auscultation.
ECG shows sinus bradycardia and QRS complex duration of 98 msec.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Sinus bradycardia is usually asymptomatic and does not require treatment. However, a minority of patients become symptomatic. In these patients, reversible causes (eg, offending medications) should be addressed prior to further workup or intervention (eg, pacemaker). Donepezil, a cholinesterase inhibitor, can cause bradycardia or heart blocks, even in patients without prior history of conduction abnormalities. Its use has been associated with dizziness and syncopal spells in Alzheimer disease patients, although these are not common side effects. As a result, the next step for this patient should be to discontinue the drug and monitor for symptom resolution. (Choice A) Clonidine, a central sympatholytic agent (ie, stimulates inhibitory alpha2-adrenoceptors), controls blood pressure effectively. However, it can cause bradycardia and should not be used in this patient. (Choice C) ACE inhibitors can cause dizziness or presyncope due to marked reduction of blood pressure. However, this patient has no orthostatic hypotension. (Choice D) Coronary artery disease with left ventricular dysfunction can cause ventricular arrhythmias and present as recurrent episodes of dizziness or syncope. However, this patient's absence of other angina symptoms makes this less likely. A pharmacologic stress test is therefore not needed at this time. (Choice E) Tilt table study is useful in patients with recurrent dizziness or syncopal episodes that are thought to be due to vasovagal or neurocardiogenic syncope. Neurocardiogenic syncope should be considered if the symptoms continue despite stopping donepezil. Educational objective: A number of drugs can depress the sinoatrial node and cause symptomatic sinus bradycardia. All medications with this potential should be withdrawn or discontinued in symptomatic patients before further evaluation or treatment. These common medications include digoxin, beta blockers, calcium channel blockers, clonidine, amiodarone, and donepezil. __________ References: Cholinesterase inhibitors and incidence of bradycardia in patients with dementia in the veterans affairs new England healthcare system. (http://www.ncbi.nlm.nih.gov/pubmed/19793162) Comparison of adverse drug reactions with donepezil versus memantine: analysis of the French Pharmacovigilance Database. (http://www.ncbi.nlm.nih.gov/pubmed/20699079) Syncope and its consequences in patients with dementia receiving cholinesterase inhibitors: a population-based cohort study. (http://www.ncbi.nlm.nih.gov/pubmed/19433698)

An 86-Year-Old Woman Is Evaluated in the Office for a 2-Month