ATRIAL FIBRILLATION

LEARNING OBJECTIVES
After completing this
case study, the reader
should be able to:
Determine
therapeutic goals for
attaining ventricular
rate control
or normal sinus rhythm
in patients with heart
disease presenting
with recurrent
paroxysmal atrial
fibrillation.
Describe the
difference between
recurrent paroxysmal
and
persistent atrial
fibrillation.
Understand the
influence of obstructive
sleep apnea on the
recurrence
and risk of incident
atrial fibrillation.
Recognize the
importance of
identifying and
alleviating
sleepdisordered
breathing in patients
with atrial fibrillation,
hypertension
and obstructive sleep
apnea.
PATIENT PRESENTATION
Chief Complaint
I feel tired and dizzy
during the day, and my
heart feels like it is
pumping too fast.
HPI
Mark Finley is a 53-year-
old man who presents
to the Emergent
Care Clinic with heart
palpitations and
dizziness. He has a 2-
year
history of recurrent
paroxysmal atrial
fibrillation. He now has
morning headaches and
feels tired throughout
the day despite
sleeping 78 hours each
night. At his last visit 6
months ago he was
in normal sinus rhythm.
He has gained 6 kg since
his last visit. The
severity of his dizziness
fluctuates; the dizziness
is worst in the
morning and during
exercise. He has been
seen by his primary care
provider in the Internal
Medicine Clinic for
many years for HTN
and recurrent
paroxysmal atrial
fibrillation.
PMH
HTN (previously well
controlled on current
antihypertensive
regimen)
Recurrent paroxysmal
atrial fibrillation (rate
controlled)
FH
Both parents had HTN;
father had obstructive
sleep apnea and died
of an early morning
stroke at age 52,
mother died in MVA at
age 63.
He has one brother who
has hypertension.
SH
Mr. Finley manages a
local grocery store and
lives at home with his
wife. He smoked 1 ppd
for 10 years and quit 2
years ago. He drinks
12 glasses of wine each
week.
Meds
Lisinopril 20 mg po daily
Metoprolol 50 mg po
twice daily
Amlodipine 10 mg po
daily
Hydrochlorothiazide 25
mg po daily
Warfarin 5 mg po daily
All
NKDA
ROS
Headache but no
blurred vision, chest
pain, or fainting spells;
complains of being tired
during the day; mild
SOB; 2+ pitting
edema
Physical Examination
Gen
Cooperative overweight
man in moderate
distress
VS
BP 149/84 (supine), P
118 (irregular), RR 20, T
36.3C; Wt 108.3 kg,
Ht 5'11''
Skin
Cool to touch, normal
turgor and color
HEENT
PERRLA, 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 wheezes and
rales bilaterally no
rhonchi
CV
Tachycardia with
irregular rate; normal
S1, S2; (+) S3; no S4
Abd
NT/ND, (+) BS; no
organomegaly, () HJR
Genit/Rect
Stool heme ()
MS/Ext
Pulses 1+ weak, full
ROM, no clubbing or
cyanosis
Neuro
A & O 3; CN IIXII
intact; DTR 2+, negative
Babinski
LAB TEST RESULTS
ECG
Atrial fibrillation,
ventricular rate 97 bpm,
mild LVH
Echo
Evidence of diastolic
dysfunction (LVEF 59%,
LVEDP 15 mm Hg)
and moderate left atrial
enlargement (5.3 cm).
No thrombus seen.
Chest X-Ray
Bilateral basilar
infiltrates
Assessment
Recurrent paroxysmal
atrial fibrillation:
moderately
symptomatic.
Diastolic heart failure:
preserved ejection
fraction with increased
LVEDP, pulmonary and
peripheral edema; start
furosemide.
Possible sleep apnea:
schedule sleep study
during hospitalization.
HTN: maintain meds for
blood pressure control.