Two of the commonest reasons a neurology outpatient never receives an effective drug are a resting pulse in the fifties and a first-degree block on an old ECG. Neither is a contraindication on its own, and both are easier to act on if the baseline is written down.
So make it a fixed step: resting pulse and a 12-lead ECG recorded in the notes before starting any rate-slowing or cholinergic drug, with the date. The point is not to find a reason to withhold. It is that four weeks later, when the pulse is 52, you can say whether that is new.
The same note should list every other rate-slowing agent the patient is on. Most drug-induced bradycardia in this group is additive - a beta blocker, a rate-limiting calcium channel blocker and a cholinesterase inhibitor arriving from three different clinics - and no single prescriber ever sees the combination.
- Record resting pulse and a dated 12-lead ECG before starting a cholinergic or rate-slowing drug
- List all other rate-slowing agents in the same note - bradycardia here is usually additive
- Recheck at four to six weeks, and after every dose increase
- Ask about syncope and falls at each review; they matter more than the number itself
- Refer to cardiology for high-grade block rather than quietly stopping an effective drug
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