One of my favorite things to ask Alexa to play me in the morning is “Coffee Shop music” while sipping on coffee planning my day out. Calms my heart rate. Ironically my thoughts turn to a 45 year old gentleman with an elevated heart rate (HR). He was admitted to ICU for COVID-19 sepsis. Had a long ICU stay but improved drastically. He started having persistent sinus tachycardia in the 100-120s after transfer to floor. He was towards the tail end of high dose Dexamethasone course. He complained of palpitations, intermittent vertigo and nausea worse on any movement, especially standing, but his BP including orthostatic BP, temperature and oxygentation stayed normal. His labs had been normal the last few days, didnt have much of a medical history or alcohol history and wasn’t on any prescription meds that could cause withdrawals. His sinus tachycardia was ascribed to anxiety from vertigo, lack of sleep and started on Meclizine and low dose Ativan. Since he had not been eating / drinking well while in ICU and had received diuretics, a liter of IV gentle hydration was tried as well. HR stayed in the 100-120s/min.
Routine labs couple days later showed a Hemoglobin of 8.5, was at 12 three days ago. Sure enough later afternoon he had a black stool later confirmed as gastric ulcers on EGD, likely stress ulcers and from use of high dose Dexamethasone. An earlier Hemoglobin check would have shortened his hospital stay by 1-2 days.
His heart was telling us a story that we heard but didn’t listen to earlier…
Learning points:
- Sinus tachycardia is often benign and physiologic , but can also be the first SOS signal that the heart sends about declining blood volume or tissue perfusion where tachycardia compensates for reduced perfusion pressure [ i.e. BP is normal BECAUSE the HR is up] OR secondary to drop in vital blood nutrients (Oxygen, Hemoglobin, glucose). Our Hypotension Mnemonic ( SHOCKED ) is a good one to think about pathologic causes of sinus tachycardia tool. So even when BP is normal, elevated HR ca signal something coming on – bleed, sepsis, dehydration, PE, etc.
- Orthostatic vertigo can in fact be a cardiovascular issue and may not be the classic “lightheaded” orthostatic symptom even if BP doesn’t drop much.
- GI bleeds can manifest clinically late and can cause cardiovascular symptoms first – like in the case above and also in this Syncope case . On a side note, know that hemoglobin may not drop initially.
- For any symptom or sign – however benign it may seem – give a thought to critical / dangerous causes to rule out. Like I have said before, common causes are common but missing a critical cause can be death 💀and a lawsuit.☠
Don’t miss these fun posts! Subscribe via email 📩 | |
