Dear friend, welcome and thanks for entrusting your query here at Healthcaremagic!
I am Dr. Prasad Akole (Critical Care Expert- http://bit.ly/Dr-Prasad-Akole) and am glad to address to your query here.

A well placed query indeed!
I studied your history and reports. I gather that he, at 65 years of age, has high BP needing treatment and smokes (/d). Has high cholesterol.

All these are high risk factors for an ischaemic heart disease (IHD). The Coronary artery disease (CAD) causes less blood supply to the heart and making prone to heart attack.

The echo is normal and TMT shows low tolerance, probably due to respiratory problem and breathlessness. It does not rule out CAD. He does not asthma, but probably COPD (chronic obstructive pulmonary disease) secondary to smoking.

His symptoms are due to VPCs (venricular premature complexes) where heart beats are abnormally placed inbetween the normal beats. This is well picked up in the Holter report. VPCs may make manual calculation of heart rate inaccurate if the extra systole has low cardiac output and is not well felt.

The seloken XL and angizem both slow the A-V conduction in the heart and can promote extra beats by slowing the heart rate below the threshold refractory period of the heart.
The rate may not have been very low< 60 at the doctor’s. He mentions 68/min.

In his case, the causes can be
1)     underlying IHD/ CAD- needs a coronary angiography for evaluation. Jaw
pain, rhythm abnormalities, dyspnoea may be indicative.
2)     Hypercapnoea- high carbon dioxide from COPD and spasm- can cause
VPCs
3)     Low potassium- from excess aerocort use, which has a Beta agonist
4)     Excess aerocort increasing arrhymogenicity of the heart.

He had no dizziness so far probably because the rate was not very low.

I would advise him to test potassium levels, optimize use of aerocort under a pulmonologist’s guidance and to appropriately manage COPD (if not already) (his breathlessness seems significant). Get an ABG (arterial blood gas) analysis done.

Get further cardiac evaluation to look for significant CAD (like angiography, stress echo).
Control diet to reduce cholesterol. Take adequate rest.

Be careful on turning neck and getting up. Keep close watch on BP and heart rate.
Be advised about angizem and seloken use by your cardiologist (as possible rate slowers).
Try an anxiolytic under supervision.

He should lie flat at any sign of slow heart rate or giddiness.

I hope to have answered your query satisfactorily. I would be glad to answer any further queries. Please ask for any clarifications before closing and rating this answer.
Take care and please keep me informed of your progress at http://bit.ly/Dr-Prasad-Akole
Good Luck! Thank you!!

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I would advise at least a potassium and ABG initially. About COPD evaluation , Xray and angiography, I think you should ask the cardiologist after these tests rule out any problems with potassium, CO2.

If the bradycardia is more pronounced in the left position, one should suspect a sick sinus (a sensitive sinus in the neck carotid vessel which if sick, can cause low to high rate variations.
Has it been considered? That is the only condition that can produce positional arrthythmia.
Also twisting, turning the neck too much or pressing on the neck could cause slowing.
Ask if a tilt table test is needed.

Does he have any sweating, nausea, chest pain?
Does he have any other disease?

I hope this helps !

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