72 years old, male.
Diagnosis: Atrial Fibrillation at medium/high ventricular response
- In 1995 TIA (Transitory Ischemic Attack) which the MRI showed to be an ischemic lesion in the left parietal-temporal-occipital area.
- Since 1992 AF (Atrial Fibrillation) for which in 2005 two ablations in Left Atrium (LA) were performed both being ineffective; at the Holter test in 2002 pauses longer than 2 seconds in the night-time (max 2,96 sec. at 2,50), in 2004 Holter without pauses. These examinations are being attached with the latest Holter test performed in November, 2008.
During medical tests performed in October, 2007 the diagnosis of chronic AF (Atrial Fibrillation) with a slight biatrial dilation was confirmed; partial control of ventricular rate (often at around 100 bpm at rest, 150-160 under stress) with digoxigenin at low dosage (digoxinemia 0,5-0,6 with Lanoxil 0,250 mg/daily), patient always in a good hemodynamic compensation; patient on OAT (Oral anticoagulant therapy) with usual INR around 3; no evidence of ischemia in myocardial scintigraphy under stress in 2002.
At the end of these medical tests the two following pharmacological therapeutic options were suggested:
- to continue taking digoxigenin, increasing its dosage: Lanoxin 0,250 1 tablet + Lanoxin 0,125 1 tablet, monitoring the digoxinemia at regular intervals;
- to pass to a beta-blocker, for example Atenolol, starting with 100 mg ½ tablet in the morning, adding, if necessary ¼ tablet in the evening, proceeding, afterwards, with 100 mg in the morning, if the drug will be tolerated after about ten days.
The patient chose the second option replacing the therapy with digoxigenin with the beta-blocker and, at present, the home therapy consists of:
- Lopresor 100 mg ½ tablet twice daily (at first atenolol that, however, was not well tolerated by the patient);
- Sintrom according to INR.
Since the patient has started taking the beta-blocker, he has noticed a vertigo sensation with a slight progressive reduction of his physical performances.
At present, anyway, the patient practises a moderate physical activity playing tennis three times a week besides working out.
At present, the heart rate at rest is generally around 90-100 bpm, while after playing a tennis match it increases to 160-170 bpm.
To define the present clinical condition the results of recent medical reports of the latest performed cardiac medical tests are reported, the pictures of which you will find in the enclosure:
Holter test performed on 11/2008:
- Total Arrhythmia due to Atrial Fibrillation throughout the all the RV media recording (91 bpm, min 49 bpm, max 150 bpm)
- Present 1 pause longer than 2 seconds (2.22 sec at 09:57 a.m.)
- Occasional isolated VEB (82), 1 couple
- Stable the alterations of the ST-Segment
Color doppler echocardiography on 11/2008:
“Examination performed on patient in AF at medium/high ventricular response.
- Regular left ventricular cavity dimensions (Telediastolic diameter=49mm; Telesistolic diameter=27 mm; Telediastolic volume=80ml) with slightly increased (=12mm) intraventricular septum end systolic thickness; no considerable alterations of the systolic thickening on the segments of the ventricular profile; uncompromised global systolic function (EF>60%).
- Right ventricular cavity with normal dimensions and kinesis.
- Minimal mitral valvular regurgitation.
- Slight biatrial dilation (antero-posterior left atrial diameter = 46 mm).
- Within normal limits the dimensions of the aortic root (=36 mm) and of the proximal segment of the ascending aorta”.
In the end it is reported that the patient has decided, by himself, to double since 1 week the therapy with Lopresor (passing from ½ tablet twice daily to 1 tablet twice daily) without any influence on the heart rate that remained unchanged.