Case report

Patient is a 69 year old man with longstanding diabetes (Type 2 requiring insulin). PH of MI in 1990. Lives with wife able to play 9 holes of golf usually lifetime non smoker BMI 36. Medication prior to February 2014 – Aspirin 75mg od, Ramipril 10mg od, Furosemide 40mg od, Isosorbide Mononitrate 20mg bd, Orlistat tds, Atorvastatin 20mg od, Insulin glargine 90 units nocte, Novorapid penfil 29 units mane and lunchtime, Metformin 850mg bd, Doxazosin 4mg od. An example of polypharmacy but has well controlled blood pressure and is reasonably well. Recent echocardiogram normal.

February 2014 – presents with shortness of breath and ankle swelling. Found to be in AF rate 120 and signs and symptoms of LVF. I made a diagnosis of failure secondary to fast AF and initiated a beta bloker for rate control and increased his diuretics, at this point I also requested a further cardiological opinion re the possibility of cardioversion.

February – June 2014 Patient reviewed regularly – AF with rate of 80-100 still SOB discussion re warfarin considering the patients age, previous MI and Diabetes – patient initially unsure, given prodigy leaflet on warfarin in AF – he decides to go ahead. Warfarinisation carried out as per practice protocol uneventful. He did not appear to be tolerating the beta blocker so on discussion with the cardiology consultant and pending his appointment in cardiology I have started Sotolol.

June 20014 – goes privately to cardiologist who arranges an echo, this shows gross lvf with a large diskinetic anterior segment consistent with a new MI, spironolactone and bumetanide started and the sotolol was changed to amiodarone, improvement in shortness of breath.

This case illustrates a number of points:-

• I correctly identified the AF
• The treatment choices for the AF were appropriate
• Appropriate use of anticoagulation – practice protocol available
• I failed to identify the MI – the initial ecg taken at the practice does not show changes (apart from AF) and the cardiologist commented before the echo “the ecg shows AF” after the echo he reviewed the ecg and still does not identify ischaemia
• This patient is currently taking “best evidence” medication

I will over the next year review the interpretation of ECGs