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CC/5(1) Complaints of periodic rapid heartseat and dizzine, lack of Medical history Contestines of rapid heartbeat and dizziness appeared. The episodes irregularly, seven from 1 to 15 minutes. the sought medical help one and wapend to treat his rapid heartbeat, but be decided not to take them due to concassent possible side effects Four months prior to the current visit, a medical examination was performed, which did reveal a changes. He is 53 years old. Retired military officer. Not registered with a doctor, arrently not taking any medication. Does not smoke, denies alcohol or drug use. Drinks 2-3 cup of fee day Objectively: Moderately severe condition due to shortness of breath and chest discond Consciousness is clear, frightened, BM1-25.8 kg/m2. Skin is pale, sweaty, visible mucous membranes are clean. Peripheral lymph nodes are not enlarged. Thyroid gland not palpable. No visible deformities of the osteoarticular system. Nasal breathing is free. Chest is cylindrical in shape, both halves participate symmetrically in the act of breathing. Vesicular breathing in the lungs, no wheezing, respiratory rate 25 per minute. On examination, the heart area is unchanged. The boundaries of relative cardiac dullness we within normal limits. Heart sounds are muffled, heart rate is 200 beats per minute. Blood pressure is 90/60 mm Hg. The tongue is clean. The abdomen is soft and painless on palpation. Liver at the edge of the costal arch. Spleen not enlarged. Stool normal. Percussion symptom negative on both sides. Urination free, painless. No peripheral edema. During the appointment, the patient felt nauseous, dizzy and had palpitations. An ECG was performed urgently: VR AVL aVF CBC: Hb-115 g/l, erythrocytes 3.54 x 1012/1, leukocytes - 5.1 x 109/1, thrombocytes-250 x 10/1, ESR-8 mm/hour. Biochemical test; glucose-6.1 mmol/l, cholesterol - 8.12 mmol/l, LDL-3.65 mmol/l, HDL -0.87 mmol/l, triglycerides - 2.65 mmol/l, creatinine - 95 µmol/l Urine analysis, relative density of urine 1.025, protein - negative, glucose - negative, epithelium - 0-1, red blood cells unchanged-1-2, white blood cells-negative. Assignment for student: 1. Establish and justify the complete clinical diagnosis according to the latest international classification specifying the disease activity, complications of the underlying disease (if present), and comorbidities ( present). Do not use abbreviations or acronyms. 2. Interpret the data of all presented laboratory analyses and instrumental examination methods. Wh laboratory and instrumental methods should be added, and what changes are characteristic of this diseas 3. Determine the management and treatment strategy for the patient, including non-pharmacological pharmacological interventions. Specify the therapeutic classes and names of drugs for etiolog pathogenetic, symptomatic, and/or replacement therapy, and provide a comprehensive plan for an follow-up and routine monitoring.

Reading File

Quick answer

Most likely working diagnosis
  1. Paroxysmal supraventricular tachycardia, currently sustained, symptomatic, and haemodynamically poorly tolerated, with probable regular narrow-complex tachycardia at approximately 200 beats per minute.
    • Likely mechanisms include atrioventricular nodal re-entrant tachycardia or atrioventricular re-entrant tachycardia.
    • The exact mechanism cannot be confirmed because the actual electrocardiogram tracing is not included in the case text.
  2. Acute haemodynamic compromise during the tachycardia episode, manifested by arterial hypotension, shortness of breath, chest discomfort, pallor, diaphoresis, dizziness, nausea, and fear.
  3. Mixed dyslipidaemia: marked hypercholesterolaemia, low high-density lipoprotein cholesterol, and hypertriglyceridaemia.
  4. Mild anaemia, pending classification by red-cell indices and iron studies.
  5. Overweight, with body mass index of 25.8 kilograms per square metre.
A suitable full clinical wording would be:
Paroxysmal supraventricular tachycardia, recurrent and currently sustained, with symptomatic arterial hypotension and clinical signs of reduced haemodynamic tolerance. Mixed dyslipidaemia. Mild anaemia of undetermined type. Overweight.
Do not diagnose atrial fibrillation, atrial flutter, ventricular tachycardia, or pre-excitation syndrome without reviewing the electrocardiogram.

Interpretation of the presented findings

Clinical findings

  • Heart rate of 200 beats per minute with recurrent abrupt attacks lasting 1 to 15 minutes strongly suggests a paroxysmal tachyarrhythmia.
  • Blood pressure of 90/60 millimetres of mercury, dyspnoea, chest discomfort, dizziness, nausea, sweating, and pallor indicate poor tolerance of the rhythm disturbance.
  • There is no peripheral oedema, pulmonary crackles, hepatomegaly, or other clear evidence of chronic congestive heart failure.
  • Consumption of 2 to 3 cups of coffee daily can trigger palpitations in susceptible people, but it should not be assumed to be the only cause.

Complete blood count

  • Haemoglobin: 115 grams per litre, low for a 53-year-old man.
  • Erythrocyte count: 3.54 × 10¹² per litre, reduced.
  • Leukocytes: 5.1 × 10⁹ per litre, within the usual reference range.
  • Platelets: 250 × 10⁹ per litre, within the usual reference range.
  • Erythrocyte sedimentation rate: 8 millimetres per hour, not suggestive of active systemic inflammation.
This is mild anaemia. Mean corpuscular volume, mean corpuscular haemoglobin, red-cell distribution width, reticulocytes, ferritin, serum iron, transferrin saturation, vitamin B12, folate, renal function trend, and assessment for occult gastrointestinal blood loss are required.

Biochemistry

  • Glucose: 6.1 millimoles per litre. If fasting, this is impaired fasting glucose and should be confirmed with repeat fasting glucose and glycated haemoglobin.
  • Total cholesterol: 8.12 millimoles per litre, markedly elevated.
  • High-density lipoprotein cholesterol: 0.87 millimoles per litre, low.
  • Triglycerides: 2.65 millimoles per litre, elevated.
  • Creatinine: 95 micromoles per litre, apparently preserved renal function, though estimated glomerular filtration rate should be calculated.
There is a data inconsistency: with total cholesterol 8.12, high-density lipoprotein cholesterol 0.87, and triglycerides 2.65 millimoles per litre, a calculated low-density lipoprotein cholesterol would usually be closer to approximately 6.0 millimoles per litre, not 3.65. Repeat a fasting lipid profile, preferably with direct low-density lipoprotein cholesterol or apolipoprotein B measurement.

Urinalysis

No protein, glucose, pyuria, or clinically significant haematuria. This does not suggest renal or urinary tract disease.

Investigations needed now

Immediate cardiac evaluation

  1. Twelve-lead electrocardiogram during the episode, with review of:
    • QRS width
    • rhythm regularity
    • atrial activity and P waves
    • evidence of pre-excitation
    • ischaemic changes
    • corrected QT interval
  2. Continuous cardiac monitoring.
  3. Repeat twelve-lead electrocardiogram after conversion to sinus rhythm.
  4. High-sensitivity cardiac troponin, especially given chest discomfort and hypotension.
  5. Serum potassium, magnesium, calcium, sodium, and bicarbonate.
  6. Thyroid-stimulating hormone and free thyroxine, because thyroid excess can provoke tachyarrhythmias.
  7. Transthoracic echocardiography to identify structural heart disease, ventricular dysfunction, valve disease, atrial enlargement, or cardiomyopathy.
  8. Ambulatory electrocardiographic monitoring:
    • 24 to 72-hour Holter monitoring if episodes occur frequently
    • longer event monitoring if attacks are infrequent
  9. Exercise testing or coronary evaluation if symptoms, electrocardiogram findings, troponin results, or cardiovascular-risk assessment raise concern for coronary disease.

Acute management

This patient should be managed in an emergency setting. He has tachycardia with hypotension, chest discomfort, dyspnoea, and presyncope, which are features of haemodynamic instability.

If instability persists

The preferred treatment is:
  • Immediate synchronized electrical cardioversion, with monitoring and appropriate analgesia or procedural sedation if this does not delay treatment.
  • Establish intravenous access, give oxygen only if hypoxaemic, monitor blood pressure and oxygen saturation, and obtain emergency cardiology input.

If blood pressure and symptoms stabilize, and the rhythm is regular with a narrow QRS complex

  1. Vagal manoeuvres, preferably a modified Valsalva manoeuvre.
  2. If ineffective, intravenous adenosine under continuous electrocardiographic monitoring.
  3. If adenosine is contraindicated or ineffective and the patient remains stable, a rate-slowing calcium-channel blocker such as verapamil or diltiazem, or a beta-blocker such as metoprolol, may be considered by the treating clinician.

Important safety point

Do not give atrioventricular-node blocking drugs blindly if the electrocardiogram shows:
  • a wide-complex tachycardia,
  • an irregular tachycardia,
  • suspected pre-excited atrial fibrillation,
  • or uncertainty whether the rhythm is ventricular tachycardia.
In those settings, urgent specialist-directed treatment is required.

Long-term strategy after rhythm confirmation

Rhythm prevention

  • Refer to cardiology, ideally a cardiac electrophysiology service.
  • For recurrent symptomatic atrioventricular nodal re-entrant tachycardia or atrioventricular re-entrant tachycardia, catheter ablation is often the definitive treatment and may avoid lifelong medication.
  • If ablation is deferred or unsuitable, preventive therapy may include a beta-blocker such as metoprolol, or a non-dihydropyridine calcium-channel blocker such as diltiazem or verapamil, selected according to blood pressure, ventricular function, electrocardiogram findings, and comorbidities.

Lifestyle and precipitant management

  • Reduce or temporarily stop caffeine while the rhythm diagnosis is being clarified.
  • Avoid stimulant drugs, energy drinks, decongestants containing sympathomimetics, and recreational stimulants.
  • Maintain adequate hydration and regular sleep.
  • Weight reduction toward a healthier body mass index.
  • Regular moderate physical activity only after acute assessment and cardiac clearance.

Lipid management

  • Repeat fasting lipid testing to confirm results.
  • Assess total cardiovascular risk, including blood pressure, glycaemic status, family history, and evidence of atherosclerotic cardiovascular disease.
  • Given the markedly raised total cholesterol, pharmacological lipid lowering is likely indicated. A high-intensity statin such as atorvastatin or rosuvastatin would commonly be considered, then adjusted to cardiovascular risk and treatment response.
  • Evaluate secondary causes of dyslipidaemia, including diabetes, hypothyroidism, liver disease, nephrotic syndrome, and dietary factors.

Anaemia management

  • Identify the cause before treatment.
  • If iron deficiency is demonstrated, investigate the source. In an adult man, gastrointestinal blood loss must be considered.
  • Treat with iron, vitamin B12, folate, or other replacement only when the deficiency has been documented.

Follow-up and monitoring

  • Early cardiology review after emergency stabilization.
  • Home pulse and blood-pressure monitoring if available.
  • Seek emergency care immediately for recurrent rapid palpitations with fainting, persistent chest pain, severe breathlessness, confusion, or low blood pressure.
  • Review electrocardiographic monitoring and echocardiography results.
  • Repeat lipid profile approximately 4 to 12 weeks after starting or changing lipid-lowering therapy.
  • Check liver enzymes before and when clinically indicated after statin therapy.
  • Repeat complete blood count and targeted anaemia studies.
  • Measure fasting glucose or glycated haemoglobin to clarify whether impaired glucose regulation is present.
The key immediate issue is not the lipid abnormality or mild anaemia. It is the symptomatic tachycardia with hypotension, which requires urgent rhythm documentation and stabilization.
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