Both atrial fibrillation and sick sinus syndrome (a subset of which is also known as “tachy-brady” syndrome) are more common in elderly patients. The problem comes when they co-exist and as a result, make management of each disease more challenging. Let’s illustrate with a case.
Case. Mrs. Robertson is an 85-year-old patient with a history of long-standing paroxysmal atrial fibrillation (AF). She has been taking dabigatran and metoprolol 50 mg twice daily. She also takes lisinopril 10 mg and metformin 500 mg BID. Recently, she has started complaining of episodes of palpitations with feelings of heart racing followed by episodes of lightheadedness. The episodes occur 1-2 times a day and usually last for a few minutes. You are concerned about whether these represent poorly rate-controlled AF.
1. What type of monitoring do you recommend?
A. Weekly ECG
B. 48h Holter monitor
C. 7d event monitor
D. Implantable loop recorder