An 86-Year-Old Woman Is Evaluated in the Office for a 2-Month

An 86-year-old woman is evaluated in the office for a 2-month history of lightheadedness with episodes of near-syncope and imbalance that last for seconds.  She has had no syncope or falls.  The patient lives in a personal care home and performs most of her daily activities with some assistance.  Her medical problems include mild Alzheimer dementia, hypertension, coronary artery disease with coronary artery bypass grafting, and mitral valve repair 10 years ago.  Her medications include aspirin, quinapril, amlodipine, simvastatin, and donepezil.
Her blood pressure is 162/82 mm Hg supine and 155/85 mm Hg standing.  Her pulse is 50/min.  Pulse oximetry is 96% on room air.  She is alert and oriented to time and place.  Cardiac examination shows a II/VI holosystolic murmur present at the apex.  There are no carotid bruits.  Lungs are clear to auscultation.
ECG shows sinus bradycardia and QRS complex duration of 98 msec.
Which of the following is the best next step in management of this patient?

A) Adding clonidine for better blood pressure control
B) Discontinuation of donepezil
C) Discontinuation of quinapril
D) Pharmacologic stress testing
E) Tilt table testing

Correct Answer:

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