Worsening Heart Palpitations With Hypertension and Obesity: A Case Study

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A patient has experienced heart palpitations for the past week, which became worse after mowing his lawn in the hot summer sun. <i>Photo Credit: ISM / Sovereign</i>
A patient has experienced heart palpitations for the past week, which became worse after mowing his lawn in the hot summer sun. Photo Credit: ISM / Sovereign

Case

A 46-year-old man presents to the emergency room having had palpitations for the past week that became worse while mowing his lawn in the hot summer sun. He has a past medical history of hypertension, obesity, and hyperlipidemia, but no prior cardiac history. He denies chest pain but reports some mild dyspnea. Family history is unremarkable.

Physical exam in the emergency room reveals a morbidly obese man with a body mass index of 34, normal S1 and S2 heart sounds with an irregular rhythm, and tachycardia. Electrocardiogram (ECG) shows atrial fibrillation (AF) with a heart rate of 142 beats per minute and nonspecific ECG changes.

 

He is started on intravenous heparin and admitted for rate control with metoprolol. The following day he undergoes a transesophageal ECG with monitored anesthesia, which does not reveal any significant valvular abnormalities and no left atrial appendage thrombus. However, it is noted that his saturations drop to 87% shortly after the administration of propofol. He undergoes successful electrical cardioversion back to sinus rhythm with 200 joules. He is started on dabigatran and metoprolol.

What is the next best step after discharge?

A. Schedule patient for outpatient Holter monitor

B. Refer patient for polysomnography

C. Refer patient for follow up with an electrophysiologist

D. Discontinue dabigatran and start warfarin

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