Man Whose Smartwatch Keeps Warning Him About A Slow Heart Rate — Free SCA Practice Case
Man whose smartwatch keeps warning him about a slow heart rate
Station Timer
12:00
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
12:00
Golden MinuteFive cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Patient Profile
Full Name
Winston Campbell
Age
69 years
Consultation Type
TelephoneAge
69
Situation
Telephone Consultation. Same day call.
Reason for Encounter
"Smartwatch keeps saying my heart rate is low. My wife asked me to ring."
Medical Records
- ●PMH: Stable angina. Hypertension. Mild Alzheimer's disease, diagnosed 9 weeks ago.
- ●Medications: Bisoprolol 5 mg, ramipril, aspirin, atorvastatin, glyceryl trinitrate spray, donepezil 10 mg at night (started 8 weeks ago, increased 3 weeks ago).
- ●Allergies: NKDA.
- ●Social: Retired. Lives with wife.
Recent Notes
- ●Memory clinic letter, 9 weeks ago: Pulse 58 regular, BP 138/80. ECG sinus rhythm, rate 58, PR 190 ms, QTc 428 ms.
- ●Bloods, 10 weeks ago: Normal.
Patient Script
For the friend playing the patient role
Character Overview: You are Winston Campbell, a 69 year old retired sorting office supervisor. You live with your wife Pauline, 66, in a terraced house where the bedrooms and the only toilet are upstairs. Your grandson Jordan, 17, set up a fitness watch for you a few months ago. You have had angina for five years. Nine weeks ago the memory clinic told you that you have early Alzheimer's disease, after you kept forgetting appointments and muddled the allotment society accounts. They started a memory tablet, which you call "the memory tablet", leaving the name to Pauline. The dose went up about three weeks ago. Pauline fills a weekly tablet box every Sunday and you take whatever is in it. For about two and a half weeks the watch has buzzed to say your heart rate is low, and twice in the last ten days you have come over funny on the stairs. Pauline made you promise to ring while she is at her morning shift in the hospice charity shop. It is about half past ten. You think it is a fuss over nothing. You are warm and play things down. You are vague about exact dates and tablet names, but you follow the conversation, answer readily and understand what you are told. Do not exaggerate the memory problem.
Opening Sentence: "Morning, doctor. My wife's made me ring, if I'm honest. This watch my grandson got me keeps buzzing to say my heart rate's low, forties it says, and I've had a couple of funny turns on the stairs. I'm sure it's nothing."
History if Asked (Data Gathering Phase)
- ●The funny turns: "Twice now, both going up the stairs. Halfway up I went all swimmy, everything went grey round the edges and my legs went like jelly. I grabbed the banister and sat down on the step, and after a minute or two I was right as rain." The first was about nine days ago, carrying the washing up. The second was three nights ago, going up to the toilet.
- ●Blacking out and afterwards (if asked whether he passed out, fell, was confused or hurt himself): "No, I never went out. Pauline heard me call the second time and came up, and I was talking to her the whole time. I didn't fall, I didn't hurt myself, and I wasn't muddled afterwards. She said I'd gone grey as a ghost and a bit sweaty. That's what frightened her." No wetting himself or tongue biting.
- ●The watch readings (if asked what it shows): "When I was sat down it used to say mid fifties. For the last two and a half weeks or so it's been saying forties. 44, 46, sometimes 41 in the evening in my chair. In the night it went down to 38 once. It said 45 when I looked just before I rang."
- ●Getting out of breath and tiredness (if asked about exercise or energy): "I walk up to the allotment, it's up a hill, about fifteen minutes. The last couple of weeks I've had to stop for a breather halfway. No chest pain though. I'm more tired too, nodding off in the chair in the afternoons, and I missed the allotment on Saturday because I felt washed out."
- ●Right now and standing up (if asked): "Fine, sat here. No dizziness, no pain." He gets up from a chair or bed without trouble.
- ●Being on his own today (if asked who is with him): "Nobody at the minute. Pauline's at the charity shop till about one and she's got the car."
Ideas, Concerns, Expectations
Gating note: Winston does not raise any of the following himself. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.
- ●Ideas: He thinks the watch is a gimmick and that he went up the stairs too quickly. If pressed, he wonders about his heart tablet but dismisses it. "I reckon the watch is a gimmick. And I probably just went up the stairs too quick. I know the heart tablet slows you down a bit, but I've been on that for years."
- ●Concerns: His first worry is being sent into hospital, because he gets muddled in new places now and is afraid of being kept in. "I don't want to end up stuck in a hospital. I get muddled somewhere new now, and once they've got you in there you don't come out." If the doctor explores further: "Pauline says I've been more muddled this last fortnight. I'm frightened the memory's going downhill faster than they said."
- ●Expectations: He hopes to be told it is the watch playing up, so Pauline can stop worrying, or how to turn the alerts off. "I was hoping you'd tell me it's the watch playing up, so Pauline can stop fretting. Or how to switch the beeping off."
If Asked: Medical History and Medications
Gating note: Winston answers each plainly when asked. He is vague about drug names and dates and often says Pauline would know.
- ●Angina and chest pain: "A tightness walking up hills about five years ago. They did a scan and said the pipes were narrowed, but I didn't need a stent, just tablets. None at all lately. I've hardly used the spray."
- ●Heart and blood pressure tablets: "The bisoprolol, is it? One every morning, the same for years. I took it this morning. I take one for my blood pressure too."
- ●The memory tablet: "Pauline knows the name. I take it at bedtime. They started me on a small one about two months ago and put it up about three weeks back, I think. I feel a bit sharper on it. I've been doing the crossword again."
- ●Problems with the memory tablet (if asked about side effects): "Really vivid dreams since I started it. The first week my stomach was loose, but that settled. I'm not as hungry as I was, and I get cramp in my calves some nights."
- ●Missed or extra doses and other medicines: "Pauline fills my box every Sunday, so I just take what's in it. I haven't missed any, and I wouldn't double up. No eye drops, nothing from the chemist, nothing new apart from the memory tablet."
- ●Family history and allergies: "My dad died of his heart at seventy four. No allergies."
Social History and Lifestyle Impact
- ●Home: The bedrooms and the only toilet are upstairs, so he climbs the stairs several times a day and at least once at night, and has become wary of them. Pauline is at her shift until about one and has the car. Marcia, his daughter, lives twenty minutes away and could come round if asked. Retired four years ago; allotment twice a week.
- ●Driving: "I gave up driving when the memory clinic told me. Pauline drives us now."
- ●Alcohol and smoking: A can of stout on a Saturday. Gave up smoking twenty years ago.
If Asked: Associated Symptoms
Gating note: Answers are brief and natural. The following are all negative: palpitations ("If anything it feels slow and steady"), breathlessness at rest or lying flat, swollen ankles, spinning dizziness, weakness, numbness, speech or vision problems, feeling the cold, constipation, fever, headaches, thyroid problems, and diarrhoea or being sick recently (the loose stomach was only that first week). Pauline says he snores like a train but has never seen him stop breathing.
- ●If asked about being more muddled: "The last couple of weeks, forgetting what I've gone upstairs for."
Responses to Management (The Negotiation Phase)
- ●If the doctor explains that the memory tablet can slow the heart, especially alongside his heart tablet:
- ●Reaction: Surprised. "But that's for my brain, not my heart. Nobody told me that." Once it is explained: "So which one's doing it?"
- ●If the doctor suggests stopping or pausing the memory tablet:
- ●Reaction: Reluctant and a little upset. "I waited the best part of a year for that tablet. If I come off it, will I go downhill?" He accepts a pause if told it is for his safety, not necessarily for good, and that the memory clinic will be involved. "Alright. As long as it's not just stopped and forgotten about." If the heart tablet is the one to be reduced: "Won't my chest pains come back?"
- ●If the doctor wants him seen today, at the surgery or in hospital:
- ●Reaction: Practical, and a little resistant. "Today? Pauline's got the car till about one. Can she bring me after lunch? What will you do, is it the stickers on the chest?" About hospital: "I don't want to be stuck in a corridor all day getting muddled." He agrees once he knows what will happen and why, and that Pauline can come.
- ●If the doctor explains what would happen next depending on the heart tracing, or mentions a pacemaker:
- ●Reaction: "So if it's bad on the tracing, I'd be going in? And if it's not?" On a pacemaker, anxious: "Could my heart just stop, then?"
- ●If the doctor suggests the watch is probably wrong and he can ignore it:
- ●Reaction: Relieved. "That's what I told Pauline. I'll get Jordan to switch the beeping off, then." If told the watch was right to flag it but cannot show what the heart is doing: "So it's not a gimmick after all. Jordan will be pleased with himself."
- ●If the doctor links the extra muddle to the slow heart rate or the tablets, or asks to speak to Pauline:
- ●Reaction: Hopeful but cautious: "So it might not be the Alzheimer's getting worse? That would be a weight off." On Pauline: "Please do. She does my tablets anyway. I'll only forget half of what you've told me." If the doctor gives a long list of instructions, or vague safety netting such as "ring back if it gets worse": "You've lost me a bit there. What's the main thing I need to do? Pauline will want to know exactly what to look out for." If asked to check his own pulse: "I wouldn't know where to find it."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
0 / 16 indicators checked+0−0
Positive (0/8)
Negative (0/8)
Domain 2: Clinical Management and Medical Complexity
0 / 20 indicators checked+0−0
Positive (0/10)
Negative (0/10)
Domain 3: Relating to Others
0 / 12 indicators checked+0−0
Positive (0/6)
Negative (0/6)
Clinical Learning Points
1
The Core Dilemma and the Model Plan
- ●Winston is 69, on bisoprolol for angina, and his donepezil was raised to 10 mg three weeks ago. His watch reads in the 40s and he has had two episodes of lightheadedness on the stairs. The skill is recognising a drug cause that nobody has told him about, deciding how urgently he must be seen, and changing his medicines without losing his trust or his memory treatment.
- ●Model answer: see him today in person, with pulse, lying and standing blood pressure, heart sounds and a 12 lead ECG, plus bloods for reversible causes. Withhold donepezil from tonight, keep bisoprolol for now, tell the memory clinic, involve Pauline, give practical advice about the stairs and a specific safety net, and review in one to two weeks.
- ●Also acceptable: a same day referral to the emergency department or a same day emergency care unit, especially if the practice cannot record an ECG today; making the medicine decision at today's assessment once the ECG is seen; or gradually reducing bisoprolol while keeping donepezil, provided the same day ECG goes ahead. Calling an ambulance now is more than he needs while well at rest, but it is not unsafe.
2
Why the Slow Pulse Needs Assessment Today
- ●Lightheadedness on exertion is a warning feature. It suggests the heart cannot speed up when demand rises, or that conduction is failing intermittently. In a 69 year old with angina, aortic stenosis is another cause of exertional presyncope, so listening for a murmur is part of the reason he must be seen.
- ●The Resuscitation Council UK (RCUK) 2025 bradyarrhythmia algorithm lists shock, syncope, myocardial ischaemia and severe heart failure as life threatening features, and Mobitz type II block, complete heart block with a broad QRS and a ventricular pause of more than 3 seconds as features that raise the risk of asystole.
- ●Winston has presyncope, new breathlessness on a hill, tiredness and more muddle, but no syncope, chest pain or heart failure, and he is well at rest. That places him in same day assessment in person, not an ambulance now and not a routine appointment.
- ●Emergency admission applies to a blackout, chest pain not settling with his spray, breathlessness or lightheadedness at rest, sudden confusion or drowsiness, low blood pressure, or an ECG showing complete heart block, Mobitz type II or pauses. His gradual muddle over a fortnight is a reason to see him today, not on its own a reason for admission.
3
Medicines That Slow the Heart
- ●Common culprits are beta blockers including timolol eye drops, verapamil and diltiazem, digoxin, amiodarone, ivabradine and acetylcholinesterase inhibitors such as donepezil, galantamine and rivastigmine.
- ●The British National Formulary (BNF) lists syncope as a common side effect of donepezil, arrhythmias as uncommon and conduction disorders as rare, and its interaction checker states that donepezil and bisoprolol can both increase the risk of bradycardia. The STOPP criteria flag these inhibitors as potentially inappropriate with persistent bradycardia below 60, heart block, recurrent unexplained syncope or another heart slowing drug.
- ●Donepezil has a half life of about 70 hours and reaches steady state in about 3 weeks. The full effect of the dose increase arrived just as his symptoms began, and after stopping it the effect fades over about two weeks. His pulse was 58 on bisoprolol before donepezil started, so the margin was small.
4
What a Smartwatch Can and Cannot Tell You
- ●Wrist devices count pulse waves optically, not electrical beats, so readings can be lower than the true rate, and overnight readings in the 40s can be normal on a beta blocker. A daytime resting change from usual values, with symptoms, matters far more.
- ●An alert is a prompt, not a diagnosis. Only a 12 lead ECG, with longer monitoring where needed, shows the rhythm. Advise him not to switch the alerts off.
5
The Assessment, the ECG and Blood Tests
- ●Pulse rate and rhythm, lying and standing blood pressure, heart sounds and signs of heart failure.
- ●On the ECG: rate, P waves and their relationship to QRS complexes, PR interval (first degree block is above 200 ms), dropped beats (progressive PR lengthening in Mobitz type I, a sudden dropped beat in type II), complete block, QRS width and QTc, which donepezil can prolong. Compare with the memory clinic ECG: sinus rhythm 58, PR 190 ms, QRS 92 ms, QTc 428 ms.
- ●Complete block, Mobitz type II, pauses, or a slow rate with shock, syncope, ischaemia or heart failure means emergency admission (RCUK 2025). Mobitz type I or new bundle branch block with symptoms needs same day specialist advice. Sinus bradycardia or first degree block in a well patient can be managed in primary care.
- ●Bloods: urea and electrolytes (hyperkalaemia slows conduction and he takes ramipril), thyroid function, calcium and magnesium. The memory clinic bloods predate the problem and cannot exclude a new disturbance.
6
Managing the Donepezil and the Bisoprolol
- ●Withhold donepezil from tonight because it is the most recent change and fits the timeline. In practice Pauline takes it out of the evening slots of his box. Switching to galantamine or rivastigmine is unlikely to help as they also slow the heart. For his mild disease the next step is a specialist decision. The memory clinic may restart a lower dose with closer monitoring, choose another option or advise staying off it.
- ●Be honest about memory. Some people notice a change when it is stopped. NICE guideline NG97 says these drugs should not be stopped because of disease severity alone, but stopping for an adverse effect is a different decision, and the memory clinic should be told.
- ●Do not stop bisoprolol abruptly, because rebound worsening of ischaemia can occur (BNF). Keeping it while donepezil washes out is reasonable; if the pulse stays slow afterwards, reduce gradually with an angina review. Verapamil and diltiazem would slow the heart further, and NICE CG126 advises a dihydropyridine if a calcium channel blocker is combined with a beta blocker.
- ●If he uses his glyceryl trinitrate spray he should sit down first, repeat after 5 minutes if the pain persists and call an ambulance if it has not gone 5 minutes after the second dose.
7
Follow Up, Monitoring and Referral
- ●Repeat the pulse and ECG in one to two weeks. Arrange ambulatory ECG monitoring if symptoms continue or intermittent block is suspected; the European Society of Cardiology 2021 pacing guideline advises matching the recording length to symptom frequency, so two episodes in ten days needs several days rather than 24 hours.
- ●Refer to cardiology if the slow rate persists, block beyond first degree or pauses appear, or there is a new murmur. Block that appears on a rate slowing drug often returns after the drug is stopped, because the drug can unmask underlying conduction disease, so the follow up ECG and monitoring separate reversible from persistent block.
- ●Write to the memory clinic with the findings and the change.
8
Safety Netting, Practical Safety and Communication
- ●Call 999 for a blackout, chest pain not gone 5 minutes after a second dose of his spray, breathlessness at rest, or lightheadedness that does not settle when he sits or lies down. Contact the practice the same day for another turn or increasing confusion.
- ●Until he is seen: stairs slowly with the banister, sit down at once if lightheaded, and have Pauline or Marcia with him. With the only toilet upstairs, a temporary downstairs commode is worth suggesting if turns continue.
- ●With his permission share the plan with Pauline, who fills the pill box and will bring him in, and send a short written or text summary. He gets anxious in new places and fears hospital, so say plainly what will happen and when admission would be needed.
- ●He has already stopped driving; asking about driving is part of assessing presyncope.
9
Common Mistakes in This Station
- ●Blaming the watch, or telling him to switch the alerts off.
- ●Blaming only the bisoprolol and missing that donepezil slows the heart, or missing the dose increase three weeks ago.
- ●Telling him to stop bisoprolol straight away.
- ●Booking a routine ECG for next week, or managing him entirely by phone.
- ●Not explaining what the ECG would change.
- ●Relying on the memory clinic bloods from ten weeks ago.
- ●Stopping donepezil with no repeat ECG, no monitoring plan and no letter to the memory clinic.
- ●Leaving him alone with the stairs and no practical advice, or expecting him to make his own way in.
- ●Giving a long list of instructions to a man with memory problems without involving Pauline or offering a written summary.
- ●Asking him to count his own pulse over the phone.
Further reading
From the PCCS Academy, the Primary Care Cardiovascular Society’s learning modules for primary care.
Free for practising healthcare professionals. You need a PCCS account to open these. Join the PCCS
Mapped to the RCGP curriculum topic: Cardiovascular Health.
← Back to Free SCA Practice Cases