A new patient with a history of atrial fibrillation (AF) and heart failure presents for an initial visit. The 72-year-old man denies exertional chest pain and paroxysmal nocturnal dyspnea. He is able to perform all his routine daily activities and can even climb 2 flights of stairs without dyspnea—although with more vigorous effort, he does become short of breath. He occasionally experiences pedal edema at the end of the day, but the condition resolves by morning.
HISTORY
He has long-standing hypertension, which for the past 2 years has finally been well controlled with an angiotensin-converting enzyme inhibitor and diuretics. He has organic heart disease, manifested by episodes of AF and echocardiographic findings of atrial enlargement of 5 cm, left ventricular hypertrophy (LVH), and an ejection fraction of 45%. His AF has been treated with rhythm control, by both electric and pharmacological means. At his last office visit, he was in sinus rhythm. Results of pharmacological stress testing have been negative for ischemia.
PHYSICAL EXAMINATION
Heart rate is 115 beats per minute; blood pressure, 122/78 mm Hg. Results of examination of the head, ears, eyes, nose, and throat are normal; there are no distended neck veins. Chest is clear; heart rhythm is irregularly irregular, with no S3 gallop and no murmurs. No edema is noted. The remainder of the physical findings are normal.
LABORATORY AND IMAGING STUDIES
Results of a complete blood cell count and a chemistry panel are within normal limits. An ECG confirms AF and also demonstrates voltage criteria for LVH.
