John R. Martinelli, MSIII SGUSOM Case #4: AF/RVR 01/22/14

Identifying Information

Mr. D.W. is a pleasant 63-year-old Caucasian gentleman who was admitted to SBMC on January 14, 2014.

Chief Complaint

Recurrent heart palpitations for 1 week.

History of Present Illness

This is a 63-year-old gentleman with a previous diagnosis of atrial fibrillation and rapid ventricular response first diagnosed in November 2013. He was treated with metoprolol and apixaban with adequate rate control; however, he became refractory to treatment despite increased dosing of metoprolol. Scheduled electrical cardioversion was performed today without success; therefore, he was admitted and started on sotalol, diltiazem, with continued apixaban prophylaxis. He denied any chest pain, shortness of breath, or ischemic neurologic symptomatology. Prior to this admission, he underwent an unremarkable cardiac echo as well as nuclear stress test.

Past Medical History

Chronic/Active

1. Atrial Fibrillation with Rapid Ventricular Response (refractory to treatment)

2. Hyperlipidemia

Past Surgical History

None

Medication (In-Patient)

Atrial Fibrillation with RVR:Sotalol 80mg: PO, BIDApixaban 5mg: PO, BIDDiltiazem 100mg: IV 5mg/hr + Normal Saline 0.9%: 100ml IV, 5ml/hr

Hyperlipidemia:Atorvastatin 10mg: 1 Tab, PO, HS

Allergies

NKA/NKDA

Social History

Denies smoking or illicit drug use. One or two glasses of wine or beer on weekends.

Family History

Father: HyperlipidemiaMother: Unremarkable

Review of Systems

Constitutional: No weakness or difficulty ambulating.Eye: No symptoms of visual field deficit or diplopia.Ear/Nose/Mouth/Throat: No nasal congestion, No sore throat.Respiratory: No shortness of breath, No cough, No wheezing.Cardiovascular: Palpitations as described in HPI, No chest pain.Gastrointestinal: No vomiting, diarrhea, constipation, or abdominal pain.Genitourinary: No dysuria.Hematologic/Lymphatic: No complaints of lymphadenopathy.Endocrine: No excessive thirst, weight changes, hair loss, tremors.Immunologic: No indication of autoimmune disease.Musculoskeletal: No extremity weakness or pain.Integumentary: No rash.Neurologic: Alert and oriented x 3.Psychiatric: Appropriate affect.

Physical Examination

General Appearance: Well appearing, comfortable, and in no acute distress.Vital Signs:

TP 98.4BP 141/78PR 124RR 18O2 96% (Room Air)

Integument: Normal TP to touch, dry, no pallor, scars, rash, masses.Lymphatics: No Lymphadenopathy.HEENT: Normocephalic. No neuro-ophthalmic deficits.

Unremarkable Ears, Nares, Oropharynx.Neck: Supple, no edema, masses, or lymphadenopathy.Thorax & Lungs: Clear to auscultation bilaterally. No crackles.

Cardiovascular: Irregular irregular, tachy, equal pulses at extremities, no peripheral edema.

Abdomen: Soft, non-tender, non-distended, no masses, bowel sounds present.

Genital/Pelvic: Deferred, N/A.Rectal/Prostate: Deferred, N/A.Musculoskeletal: All extremities 4+ power, bilateral DTR 2+.Neurologic: No evidence of focal deficits.

Diagnostic & Laboratory Testing

Trans-Esophageal Echocardiography (TEE): No evidence of atrial wall thrombosis immediately prior to attempted electrical cardioversion.

EKG: Consistent with refractory atrial fibrillation with rapid ventricular response.

WBC: 8.2 Na: 139 Cl: 106 BUN: 14 Glu: 128Hgb: 15.2 K: 4.0 HCO3: 23 Cr: 1.08Hct: 44.8Platelets: 191 PT: 14.1 INR: 1.3 PTT: 29.4

Summary

Mr. D.W. is a 63-year-old gentleman who was diagnosed with atrial fibrillation and an associated rapid ventricular response in November 2013. He was successfully treated with metoprolol as well as apixaban. His subsequent clinical course was without incident until approximately 1 week prior to admission, whereby he began to experience symptoms of persistent heart palpitations. His cardiologist admitted him to SBMC cath lab for ECG, trans-esophageal echo, and possible electrical cardioversion. Cardioversion proved to be unsuccessful; therefore, medical cardioversion was attempted with a trial of PO sotalol, IV diltiazem and overnight observation. Sinus rhythm was achieved several hours after initiation of therapy with regular ventricular rate. He was discharged and continued on PO sotalol, diltiazem, as well as apixaban.

Assessment

1. Atrial fibrillation with rapid ventricular response of unknown etiology, refractory to metoprolol therapy.

2. Hyperlipidemia, no evidence of coronary artery disease or myocardial ischemia/infarct.

Action Plan

1. Continue sotalol, diltiazem, and apixaban therapy, follow-up with cardiology.2. Continue atorvastatin; consider heart catheterization per EKG or recurrence of

atrial fibrillation.