November 30, 2024

75-year-old man with a history of hypertension

By Med-Challenger · 1 minute read

A 75-year-old man with a history of hypertension presents to you for evaluation of intermittent episodes of dizziness over the past several days. He is currently without any dizziness and notes no chest pain, shortness of breath, or focal weakness/numbness.

His blood pressure today is 160/80 mm Hg. Physical examination is unremarkable except for tachycardia. He is on hydrochlorothiazide for hypertension.

Electrocardiography (ECG) is obtained (see Figure).

image (30) Figure.

Based on the information provided, what would be the best next step in the management of this patient's condition?

emergent cardioversion
amlodipine
observation
intravenous diltiazem

The correct answer is:

intravenous diltiazem

This patient is presenting with symptomatic atrial flutter. Findings on ECG show evidence of atrial flutter with a 2:1 block and a ventricular rate of approximately 150 beats/minute. The next step would be to transfer the patient to the emergency department where an intravenous medication could be provided to slow the heart rate. Cardioversion is not indicated at this point as the patient is not unstable: not hypotensive, no evidence of volume overload on examination, and the patient's mentation is intact.

Atrial flutter usually runs at 150 ventricular beats/minute and 300 atrial beats/minute. In children with atrial flutter, the rate may be as high as 500 atrial beats/minute.

Reference:

Yealy DM, et al. Dysrhythmias. In Marx JA, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed., 2014.

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