Chief Complaint “Lately, I feel like my heart has been racing a bit. It really doesn’t bother me that much, but I wanted to have it checked out to be sure.
Chief Complaint “Lately, I feel like my heart has been racing a bit. It really doesn’t bother me that much, but I wanted to have it checked out to be sure.”
HPI: Cooper Riley is a 64-year-old man with heart failure and a history of persistent AF who presents to his primary care physician complaining of palpitations that he first noticed 7 days ago. He reports that he is aware of the palpitations but that he has remained relatively asymptomatic. There has not been a noticeable change in his level of fatigue or exercise capacity during his normal daily activities. Mr Riley was diagnosed with heart failure 6 years ago. For the past few years, his baseline exercise capacity would be described as slight limitation of physical activity with some symptoms during normal daily activities but asymptomatic at rest. He has a history of AF that was cardioverted to NSR, and he has been on amiodarone to maintain NSR for the past 8 months. In the office today, Mr Riley’s ECG shows that he is in AF (Picture below)
Rhythm recorded in Mr Riley’s physician’s office that depicts AF with a ventricular response rate of 110 bpm. AF is characterized by the absence of atrial “p” waves with varying distances between QRS complexes. AF is sometimes referred to as an irregularly irregular rhythm: irregular because it is not NSR; irregular because it produces an irregular ventricular response rate or peripheral pulse.
PMH Hypertension,Persistent AF (previously in NSR with amiodarone therapy)! Heart failure with reduced ejection fraction (LVEF 35%)! Obstructive sleep apnea (AHI 28 events/hr), alleviated with CPAP therapy
FH Both parents are deceased. Father died of an AMI at age 64. Mother died of breast cancer at age 70 years.
SH Mr Riley works as an accountant. He is married with two healthy children. He does not smoke but occasionally “drinks a few beers on the weekend.”
Medications Carvedilol 6.25 mg PO BID, Digoxin 0.0625 mg PO once daily, Amiodarone 400 mg PO once daily,Furosemide 40 mg PO once daily, KCl 20 mEq PO once daily, Lisinopril 10 mg PO once daily, Warfarin 5 mg PO once daily, CPAP therapy (8 cm H2O) at night
ROS Reports no change in level of fatigue, some exercise intolerance; no headache, lightheadedness, chest pain, angina, or fainting spells; 2+ pitting edema
Physical Examination
Gen Cooperative overweight man in no apparent distress
VS BP 158/92, P 110 (irregular), RR 20, T 36.3°C, Wt 108.3 kg, Ht 5′11″
Skin Cool to touch, normal turgor and color
HEENT PEERLA, EOMI; funduscopic exam reveals mild arteriolar narrowing but no hemorrhages, exudates, or papilledema.
Neck Large and supple, no carotid bruits; no lymphadenopathy or thyromegaly, (-) JVD
Lungs/Thorax Inspiratory and expiratory rales bilaterally, no rhonchi
CV Pulse 110 bpm and irregular; normal S1, S2, (+) S3, no S4
Abd NT/ND, (+) BS; no organomegaly, (-) HJR
Genit/RectNormal male anatomy; stool heme (-)
MS/ExtPulses 1+ weak, full ROM, no clubbing or cyanosis; mild edema (2+)
NeuroA&O × 3; CN II-XII intact; DTR 2+, negative Babinski
Labs
Na 140 mEq/L
Hgb 12.0 g/dL
Ca 8.5 mg/dL
K 4.0 mEq/L
Hct 35.8%
Mg 2.1 mEq/L
Cl 105 mEq/L
Plt 212 × 103/mm3
Dig 0.8 ng/mL
CO2 24 mEq/L
WBC 9.5 × 103/mm3
BUN 22 mg/dL
Polys 65%
SCr 1.1 mg/dL
Bands 2%
Glu 109 mg/dL
Lymphs 30%
INR 2.3
Mono 3%
ECGPersistent AF, ventricular rate 110 bpm.
EchoEvidence of systolic dysfunction (LVEF 35%) and moderate left atrial enlargement (5.2 cm). No thrombus seen.
Chest X-RayEnlarged cardiac silhouette; no evidence of acute pulmonary infection or edema
AssessmentPersistent AF, previously in NSR on amiodarone therapy: mildly symptomatic, appropriately anticoagulated with warfarin therapy. Ventricular response rate not controlled.
HF: mildly symptomatic, standard meds not at target doses.
HTN: not controlled; optimize therapy for blood pressure control.
OSA: controlled on CPAP therapy.
Questions:
What subjective and objective information indicates the presence of persistent atrial fibrillation with HFrEF?
What additional information is needed to fully assess this patient?
Assess the severity of Mr Riley’s AF based on the subjective and objective information available.?
What are the goals for pharmacotherapy in patients with AF?
What are the goals for pharmacotherapy for this patient’s comorbid disease states or conditions?
What nondrug therapies might be useful for Mr Riley?
What feasible pharmacotherapeutic alternatives are available for rhythm control in AF? What feasible pharmacotherapeutic alternatives are available for rate control in AF?
How effective is amiodarone therapy in maintaining NSR long-term in patients with AF?
Mr Riley has persistent AF. How is this different than permanent AF?
List the drugs that have been demonstrated to improve mortality in the setting of heart failure and AF (used scientific evidence).
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