PACE AF Clinical Cases

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PACE AF Clinical Cases
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Case 1

• Mr KP is a 50 year old civil servant with a
  family history of coronary heart disease. He
  reports suffering irregular heart beats when
  relaxing at night. He has started buying aspirin
  over the counter and simvastatin intermittently.
• On closer questioning, he sounds to be having
  missed beats on an evening but also has had 3
  episodes of heart racing for 15-20minutes when
  he felt quite breathless and sweaty.

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• Examination
• Lifestyle
• Over the counter drugs
• ECG
• 24 hour ECG which one? Pick up rate?
• Echo- should everyone have one? if exam normal
  in this case
• Paroxysmal AF- treatment, rhythm vs rate control
• Thromboprophylaxis

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Case 2

• Mrs LS suffered a myocardial infarction 10yrs
  ago. 4yrs ago she presented with symptoms of
  heart failure which were diagnosed and managed
  well in primary care !. She is currently on
  Bisoprolol 10mg od, frusemide 40mg od, ramipril
  10mg od, aspirin and statin.
• She attends for her cardiovascular review and
  reports that over the past few weeks she has felt
  more tired with increasing shortness of breath on
  exertion. Her ankle swelling has recurred along
  with short lasting episodes of left sided chest
  pain which has been worrying her.
• On examination, pulse 100irreg irreg, BP 110/70,
  JVP ?mildly raised, HS normal, basal crackles and
  oedema to mid calf.

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• ?angina/?episodes of fast af
• 24hr ecg
• ?echo
• Ttmt- diuretic dose, digoxin and warfarin
• ?refer ?cardioversion definitely if angina

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Case 3

• Miss JK is an 80yr old lady with COPD who had a
  recent infective exacerbation 3 weeks ago. She
  continues to feel more short of breath and is
  concerned that she hasnt picked up like she
  normally does.
• On examination, she is SOB on minimal exertion
  around the surgery, pulse 120irreg irreg, BP
  150/80, JVP up 2cm, HS normal, chest quiet. She
  is tender in the right upper quadrant of her
  abdomen and has oedema to mid thigh.

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• ?residual infection
• bloods,ecg, echo
• rhythm vs rate control
• cardioversion resolved precipitating factor

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Case 4

• MB is a 66yr old hypertensive man who attends for
  his routine blood pressure check. The digital
  sphyg is reporting an error and on closer
  evaluation his pulse is irregularly irregular at
  90/min. He reports no symptoms palpitations, SOB
  or chest pain and examination reveals a BP of
  140/80, HS normal and no oedema.
• He is currently on Bendrofluazide 2.5mg od and
  atenolol 50mg od

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• How long AF?
• ?rhythm control
• Aspirin vs warfarin moderate risk pt

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Case 5

• Mrs LM has known atrial fibrillation with an
  unsuccessful cardioversion 4yrs previously. She
  has been stable on digoxin 250mcg and atenolol
  50mg but the AF has become troublesome over the
  past few months with daily episodes of fast
  palpitations which are short lasting

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• Discussion re amiodarone/ ablation/ further
  cardioversion