Early Morning Palpitations
A 47-year-old Caucasian man presents to an outpatient appointment with abrupt onset of mild palpitations that occurred the same morning when he woke up, and lasted for 50 minutes during which the patient felt mild malaise. On further questioning he notes similar episodes of palpitations occurred earlier this year, approximately three times: all of them resolved spontaneously after one to three hours, and he did not seek medical attention for them. The patient denies any episodes of syncope, pre-syncope, chest pain, shortness of breath, or significant changes in exercise tolerance, temperature tolerance, or any recent changes in medications.
His medical history is significant for obesity (BMI = 34), treated hypertension (on hydrochlorothiazide 25 mg orally once daily), treated obstructive sleep apnea (he was seen at a sleep medicine center nine years ago, and he has been using a continuous positive airway pressure device [CPAP] every night since then), and history of tobacco use (15 pack/year history; he completely quit smoking 12 years ago). Patient does not have significant family history of heart disease, diabetes, cancer, or congenital abnormalities, and he is compliant with yearly preventive visits to his primary physician. Patient denies any consumption of alcohol, illicit drugs, or supplements.
Physical examination: Pulse 72 beats per minute – regular and equal in both arms, blood pressure in left arm 130/85 mm Hg and 135/85 in the right arm. No acute distress, no skin changes or rashes, no elevation in jugular venous pressure, and no carotid bruits. Lung sounds are clear bilaterally. Heart exam is significant for mild displacement of point of maximum impulse laterally, no right ventricular lift, auscultation reveals regular and crisp S1, normally split S2, no S3, no S4, and no rub. Abdominal exam is benign, and patient has no peripheral edema.
Resting ECG reveals the following:
Twenty-four hour Holter recording is ordered, and reveals daytime normal sinus rhythm with rare premature ventricular contraction, and an approximately four-hour night-time change in rhythm (between 3:35AM and 7:52AM). A brief tracing from the period of altered rhythm is shown below (recorded at 5:41:47AM).
A trans-thoracic echocardiogram is performed and shows concentric mild left ventricular hypertrophy, normal left ventricular size and function (calculated LV EF = 67%) without regional wall motion abnormalities, normal right ventricular size and function, normally functioning valves, and moderate bi-atrial enlargement. Patient's laboratory results reveal normal hemoglobin, normal thyroid stimulating hormone, and all electrolytes as well plasma creatinine are within normal limits.
Patient is started on Aspirin 325 mg orally once daily. What would be the next most appropriate step in the management of this patient?