How old is the patient, and are they an athlete? Sinus bradycardia has many potential causes – have you checked Medscape:

https://emedicine.medscape.com/article/760220-overview#a5

Thank you very much for your reply. The patient is 71 years old, he is a former athlete, a sport of freestyle wrestling. However, his pulse was always 56 ÷ 66. And the level of indirect bilirubin is very surprising

Possibly sick sinus syndrome

O. P. Strakhova I notice that you are not a cardiologist, and not actually a medical doctor. I would get a proper cardiological workup. There are so many possibilities that we out here can only guess, and this is wasting time – the sooner a proper diagnosis is made, the better.

Dear colleague, thank you for your answer. The patient is in the hospital under the supervision of cardiologists. All relevant examinations have been performed for the patient. However, with the help of laboratory and instrumental methods, it was not possible to identify the cause of the decrease in heart rate. I thought, perhaps, one of the specialists once observed similar symptoms, and could tell what the reason is.

O. P. Strakhova I am sorry to hear that, but even if someone observed similar symptoms it might not even be the same cause. I don't think that the normal BP is reassuring. Given that heart rate is down, even if stroke volume increases it's not enough to maintain normal BP. So there must be an associated vasoconstriction.

The possible causes of normotensive bradycardia are many indeed, but a lot of them are medication related – though I guess this has been checked out since it's a quick task. The other thing that may be worth remembering is Lyme disease, which doesn't tend to cross people's minds.

Thanks for your reply. I am not really a doctor, I am an engineer, although a PhD in Medical Informatics and Cybernetics. I am well aware that the similarity of the manifestations of the disease does not necessarily mean a similar diagnosis. I asked for the help of the medical professionals of the site, because a sudden guess can make it possible to understand what the real cause of the disease is, to link the patient's symptoms into a single diagnosis.

It's not quite like Lyme disease - the patient did not have a rash or a fever. However, we will do a test for borreliosis. The attending physician of this person assumes that the cause of his illness is some kind of intoxication. But not medication, that's for sure.

Dear Starkhova, although there are sufficient evidence linking obstructive jaundice and bradycardia (which cause increase in conjungated hyperbilrubinaemi), there is report of bradycardia occuring in Gilbert syndrome (ref: Curie E etal, Anadolu Kardiyol Derg:2013:13:559_65). In Gilbert's syndrome there is elevation of indirect bilirubin, similar to haemlytic anemia. So elevated indirect hyperbilrubinaemi may be a cause for bradycardia in your case.

Dear colleague, thank you very much for your answer.

I told your opinion to the attending physician. He will certainly take your considerations into account. Because so far no one has been able to find the cause of this patient's condition.

Dear O. P. Strakhova. Pl let us know about the final diagnosis. I am sorry about making mistake in the spelling of your name earlier. Best regards.

I will definitely inform you. I myself am very interested.

Dear O. P. Strakhova – I think that we are not just interested but concerned. It is worrying to have an unexplained persistent symptom, for all the people involved. We all wish the patient – and you – well, and appreciate the trouble you are taking to research their problem.

Thank you so much for your attention to my question, and empathy for the patient. I am deeply moved by such a sincere interest in him. The examination is still ongoing and will take some time. I will definitely tell you what decision will be made on the diagnosis and treatment tactics of the patient.

Dear O. P. Strakhova, you could make a search for toxic exposure to toluene, dimethyl sulfoxide (DMSO) or electrolyte imbalance.

Dear colleague, thank you for your opinion. Indeed, the general opinion of the attending physicians was: poisoning, as the cause of the patient's condition, according to the results of a biochemical blood test: high numbers of indirect bilirubin and creatinine. The patient has now undergone a general detoxification course, although no toxic agent has been identified.

For rehabilitation, with the written consent of the patient, he is given a course of electropuncture, pulse current, frequency 10; 1; 0.1 Hz, pulse duty ratio 3: 1, current strength up to 20 μA.

The heart rate is on average 60 ÷ 68 beats per minute, however, with a load, the pulse decreases to 40 ÷ 45 beats.

I will tell you how the process of his treatment will go.

Sincerely.

Dear O. P. Strakhova, thanks a lot for sharing these good pieces of information.

Colleagues, success! A patient with bradycardia, the average heart rate was 34 ÷ 38 within a month, as a result of the non-drug treatment, the average heart rate is 71.

According to the results of Holter monitoring, before treatment, the number of different types of extrasystoles is 3207 per day; after treatment -436 singles, one double.

Before treatment, grade 3 atrioventricular block (90% of monitoring time, with grade 2 episodes within 10% of monitoring time). after treatment - episodes of av1.

I will write in detail later

Dear colleagues, in the attached file - parameters identified in a patient with bradycardia disease during Holter monitoring on the dates indicated in the column headings.

After the second Holter monitoring, the patient was treated with acupuncture. Third Holter monitoring parameters are the result of this treatment.

Unfortunately, the cause of bradycardia has not been identified. Biochemical blood tests for ferritin - within normal limits. Indirect bilirubin decreased slightly, but has not yet entered the age norm. In a week the patient will undergo the next course of acupuncture.

Dear O. P. Strakhova,

I still believe that Gilbert's syndrome has to be excluded as a causes for the mildly elevated indirect hyperbilrubinaema and bradycardia.

Regards.

Dear Dr O. P. Strakhova . I agree with Dr Chowdhury/Chaudhury Meshkat Ahmed .

Dear Colleagues. Diagnostics and principles of creating a treatment regimen in acupuncture are fundamentally different from diagnostics and creating a treatment regimen in Western medicine. The treatment was aimed at restoring the balance of energy in the "meridians", by analogy with the organization of electricity flows in the power supply structures of the enterprise. The scheme of this treatment was formed by me. the work of the "liver meridian" was also stimulated, which can be indirectly considered as efforts aimed at overcoming hemochromatosis.

Dear colleagues, an interesting result about our patient with bradycardia and high indices of indirect bilirubin.

The indirect bilirubin has almost returned to normal, ten days ago. However, all this time we carried out measurements of his electrocutaneous characteristics according to a method developed and patented by us. Despite the normalization of blood biochemical parameters, electrocutaneous parameters related to the concept of "liver meridian" remain extremely high, and we continue to work on their normalization. This is especially interesting to me, in the context of the assumption that the patient has Gilbert's syndrome. Although this diagnosis was not confirmed by biochemical tests.

Depending on patient's age, it could be sick sinus syndrome

Dear colleague. For an unknown reason, the automatism of not only the sinus, but also the atrioventricular node disappeared. A week before the start of treatment with the acupuncture method , developed for this patient, the rhythm became idioventricular. Then, in the course of treatment, a sinus rhythm began to appear. It was temporary, it lasted about two or three hours, and then again the rhythm became idioventricular. After a month of treatment, it was possible to completely restore the automatism of the heart, and then for another two weeks, treatment was carried out to consolidate the result.

From the day of the end of treatment on October 31, no cases of bradycardia have been recorded.

All results are confirmed by the findings of Holter monitoring.