Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Paroxysmal Atrial Fibrillation in Patients Undergoing Cardiac Resynchronization Therapy : Challenge or Routine?


Age Gender Occupation Working Diagnosis
58 Years Female Housewife Dilated Cardiomyopathy

History

The patient has had a known cardiomyopathy for 3 years. She had coronary artery disease, with implantation of a bare metal stent (BMS) in the proximal circumflex artery in 2006. The left ventricular ejection fraction was 32% at the last visit to the cardiologist. The patient reported a rhythm disorder, but an electrocardiogram (ECG) has not been performed. She had peripheral artery disease class IIb, with a percutaneous transluminal angioplasty of the femoral artery on the left side in 2007.

Comments

The etiology of cardiomyopathy was unknown. She had cytomegalovirus-related hepatitis in the history, a myocardial biopsy revealed no active inflammation and no bacterial or viral burden, and magnetic resonance imaging did not show signs of inflammation or other structural heart disease.

Current Medications

The patient’s current medications are acetylsalicylate 100 mg/day, enalapril 5 mg/day, metoprolol succinate 95 mg/day, spironolactone 25 mg/day, torasemide 5 mg/day, and atorvastatin 20 mg/day.

Comments

The medication dosage for congestive heart failure was reduced by the cardiologist because of recurrent hypotensive episodes.

Current Symptoms

In June 2008, the patient was admitted to the hospital because of recurrent chest pain unrelated to exercise. In addition, she reported shortness of breath during minimal physical efforts.

Physical Examination

  • BP/HR: 110/70 mm Hg/68 bpm

  • Height/weight: 160 cm/53 kg

  • Neck veins: No elevation of jugular venous pressure

  • Lungs/chest: Breath sounds clear bilaterally without crackles, rhonchi, or wheezing

  • Heart: Regular rate and rhythm with systolic murmur radiating to axilla

  • Abdomen: Soft, nontender, nondistended in all quadrants; positive bowel sounds; no palpable masses

  • Extremities: Warm, without clubbing or cyanosis; slight edema at the ankles

Comments

No actual signs of cardiac decompensation are present and only slight peripheral edema as a sign of congestion.

Laboratory Data

  • Hemoglobin: 12.7 g/dL

  • Hematocrit/packed cell volume: 0.37%

  • Mean corpuscular volume: 92 fL

  • Platelet count: 237/nL

  • Sodium: 134 mmol/L

  • Potassium: 4.61 mmol/L

  • Creatinine: 0.9 mg/dL

  • Blood urea nitrogen: 51 mg/dL

  • Troponin T: <0.01 μg/L (normal, <0.04 μg/L)

  • Creatinine kinase: 44 units/L

  • Creatinine kinase–myocardial bound: 13 units/L

Comments

No relevant abnormalities were reported in the laboratory results. The myocardial markers remained normal in following tests.

Electrocardiogram

Findings

The ECG recorded a sinus rhythm, heart rate of 68 bpm, left axis deviation, left bundle branch block (LBBB), PQ interval 160 ms, QRS 160 ms, and QT 480 ms ( Figure 1-1 ).

FIGURE 1-1, 12 Lead ECG at admission showing sinus rhythm with a heart rate of 68 bpm and LBBB.

Comments

The ECG identified complete LBBB, with QRS greater than 150 ms, which had been described previously.

Chest Radiograph

Findings

Radiography findings were no infiltrates, no congestion, no pleural effusion, normal heart/thorax ratio, and normal heart size. A small calcified, circular formation was seen in the lower left lobe, consistent with a granuloma ( Figure 1-2 ).

FIGURE 1-2, Chest radiograph at admission.

Comments

The chest radiograph was normal.

Echocardiogram

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here