A
69-year-old male is referred for a one month complaint
of progressively increasing exertional dyspnea and
palpitations. Two months ago, he was placed on digitalis
because of an irregular heart rate of around 140/min.
Comorbidities inclued hypertension and dyslipidemia
and history of drinking a 6-pack beer per week. He
had a negative stress test with a reportedly normal
left ventricular (LV) ejection fraction (EF) a year
ago.
On examination, the patient is in moderate
respiratory distress. His BP is 150/92 mm Hg and the
pulse is irregularly irregular at 160/min. There is
an S3 gallop at the apex together with a grade 1/6
holosystolic murmur. The lungs are clear.
The Chest x-ray shows moderate cardiomegaly,
interstitial pulmonary edema and small bilateral pleural
effusions. The EKG shows atrial fibrillation with
a ventricular response of around 170/min. There is
slow progression of R waves across the precordium
and nonspecific ST-T changes in the inferior and lateral
leads. Dig level is 0.2 ng/dl. Echocardiogram shows
mild LV hypertrophy, mild left atrial and LV enlargement
and an LV EF of 35%.
