Scene: A cardiologist’s office
The patient, Mr. Thompson, a 58-year-old male, is seated in front of the cardiologist, Dr. Patel. Mr. Thompson has been experiencing chest pain and shortness of breath during physical activity.
Dr. Taylor: Good morning, Mr. Thompson. I understand you’ve been having some chest pain. Can you tell me more about what’s been going on?
Mr. Thompson: Good morning, Doctor. Yes, for the past couple of months, I’ve noticed this dull ache in my chest whenever I’m doing something like climbing stairs or walking briskly. It usually goes away after I stop and rest.
Dr. Taylor: Hmm, I see. Does the pain radiate anywhere, like to your jaw, neck, or arm?
Mr. Thompson: Not really. It just stays in the center of my chest.
Dr. Taylor: How about other symptoms? Any shortness of breath, lightheadedness, or palpitations when this happens?
Mr. Thompson: Yes, actually. I do feel short of breath when it happens, and I’ve noticed my heart feels like it’s racing or fluttering sometimes.
Dr. Taylor: That’s good to know. When you say your heart feels like it’s fluttering, can you describe it more? Is it irregular, or does it feel like it’s beating too fast?
Mr. Thompson: It feels like it’s beating very fast, and sometimes it’s not steady—like it skips or pauses before starting up again.
Dr. Taylor: Interesting. How long does the fluttering last when you feel it?
Mr. Thompson: Usually for a few minutes. It tends to happen when I’m exerting myself, but once I stop, it calms down.
Dr. Taylor: Have you ever noticed these episodes happen at rest, or is it only during activity?
Mr. Thompson: It’s only when I’m active. At rest, my heart feels fine.
Dr. Taylor: And do you feel fatigued or unusually tired afterward?
Mr. Thompson: Sometimes, yes. If the fluttering lasts longer, I feel wiped out after it stops.
Dr. Taylor: Alright. Let me ask about your medical history—any history of heart problems, high blood pressure, or diabetes?
Mr. Thompson: I’ve had high blood pressure for a few years now. I take medication for it, but I admit I’ve missed doses here and there.
Dr. Taylor: I appreciate your honesty. And family history—anyone in your family with heart disease or rhythm problems?
Mr. Thompson: My dad had a heart attack in his 60s, but no one else that I know of had rhythm issues.
Dr. Taylor: Okay, based on what you’re describing, I’d like to do some tests to evaluate this further. Your symptoms—chest pain, shortness of breath, and the fluttering sensation—make me suspect this could be related to an arrhythmia, possibly atrial flutter.
Mr. Thompson: Atrial flutter? What is that?
Dr. Taylor: It’s an abnormal rhythm where the upper chambers of your heart—the atria—start beating very rapidly, often in a regular but fast rhythm. This can lead to symptoms like the ones you’re describing, especially during exertion.
Mr. Thompson: Oh, I see. Is it serious?
Dr. Taylor: It’s something we can manage, but it’s important to confirm the diagnosis. I’d like to do an EKG today to check your heart rhythm and possibly order a stress test. We might also consider wearing a Holter monitor to track your heart over 24 to 48 hours.
Mr. Thompson: That makes sense. I’ll do whatever tests you think are needed.
Dr. Taylor: Great. In the meantime, try to avoid strenuous activity until we have more information. We’ll figure this out together.
Mr. Thompson: Thank you, Dr. Patel.
Dr. Taylor: You’re welcome. Let’s get started with that EKG.
This conversation naturally leads the cardiologist to suspect atrial flutter due to the patient’s exertional symptoms, palpitations, and history of hypertension. The doctor’s diagnostic plan reflects the need to confirm the suspicion through appropriate tests.
Simon Downes, MD, PhD 