Unusual Cause of Symptomatic Bradycardia. Passing Out Once Looking Right!

Abstract

A 63 year old white man with hypertension presents complaining of episodes of light headedness and generalized weakness, in the last year, more frequent in the last few weeks. He has noticed an overall decline in heart rate (HR) while exercising on treadmill. Atenolol dose was decreased a month ago with no improvement. Physical exam revealed a right sided goiter, otherwise unremarkable. Labs, EKG, Stress test and Echocardiogram were within normal limits. No pauses on the monitor. Carotid massage revealed a significant decrease in HR from 78 to 45 with lightheadedness when done on the right side. Atenolol was discontinued and he was discharged with event monitor. He returned to the hospital few days later with recurrent symptoms. Event monitor showed a sudden decrease in HR from 120 to 70 during exertion. Further questioning showed that all episodes were precipitated by turning his head to the right side. We suspected that the neck mass is compressing the carotid sinus and causing bradycardia. CT neck showed a large goiter compressing on adjacent structures. Thyroidectomy was done and patient was seen six weeks later with no more spells.