Cardiac Follow-Up

Diagnoses

CTCA Feb 25 - (Agatston score 185, 72%) right dominant, good vessel calibre, LMS minimal <25%, LAD mild <50%, LCx minimal <25%, RCA mild <50%, mild overall calcification burden Echo Feb 25 - LVEF 60%, mild MR, mild LA dilatation, normal RV function 7d ECG Feb 25 - 7d duration, mean daytime HR 74 bpm, normal diurnal variation, rare isolated VEs and SVEs, 3 runs of paroxysmal AF (max duration 4 hrs, max rate 128 bpm) ECG Feb 25 - SR, 68 bpm, normal axis, PR 162 ms, QTc 415 ms, nil acute ST-T changes Carotid Doppler Feb 25 - <30% bilateral ICA stenosis, normal vertebral flow Paroxysmal atrial fibrillation – Feb 25 - Newly detected following cryptogenic TIA Non-obstructive coronary artery disease – Feb 25 - Identified on CTCA Hypertension – Mar 18 - Essential hypertension Ischaemic stroke / TIA – Jan 25 - Left hemispheric TIA (managed by Neurology) Hypercholesterolaemia – Mar 18 - Mixed dyslipidaemia Total cholesterol 4.8 mmol/L, HDL 1.3 mmol/L, LDL 2.8 mmol/L, non-HDL 3.5 mmol/L (target LDL <1.4 mmol/L, non-HDL <2.2 mmol/L). HbA1c 39 mmol/mol. FBC, U&Es, LFTs, and TFTs all NAD.

Drug Therapy

apixaban (Eliquis®) 5 mg PO BD (commenced) clopidogrel 75 mg PO OD (stopped) atorvastatin 80 mg PO ON (increased from 40 mg PO ON) ramipril 5 mg PO OD bisoprolol 2.5 mg PO OD (commenced)

Allergies: Penicillin (maculopapular rash)

Plan And Recommendations

Commence apixaban 5 mg PO BD for secondary stroke prevention Discontinue clopidogrel 75 mg PO OD Commence bisoprolol 2.5 mg PO OD for rate control Increase atorvastatin to 80 mg PO ON to achieve target LDL <1.4 mmol/L Repeat lipid profile and LFTs in 3 months via GP Mediterranean diet and regular aerobic exercise advised Routine cardiology review in 6 months

It was a pleasure to review Arthur in clinic today to discuss his recent cardiac investigation results following his referral from the Neurology team for a recent transient ischaemic attack.

He has remained entirely asymptomatic from a cardiovascular perspective since his neurological event, denying any chest pain, exertional dyspnoea, orthopnoea, palpitations, or syncope.

His 7-day ambulatory ECG demonstrated sinus rhythm for the majority of the recording with a mean daytime rate of 74 bpm, rare isolated ectopics, and three asymptomatic runs of paroxysmal atrial fibrillation lasting up to 4 hours with a maximum ventricular rate of 128 bpm. This is a crucial finding as it provides a clear cardioembolic aetiology for his recent TIA.

His transthoracic echocardiogram showed preserved left ventricular systolic function with an LVEF of 60%, mild mitral regurgitation, and mild left atrial dilatation, which predisposes him to atrial arrhythmia. His CTCA revealed a calcium score of 185 (72nd percentile) with a right dominant system of good calibre, demonstrating minimal <25% stenosis in the LMS and LCx, and mild <50% stenosis in the LAD and RCA, indicating non-obstructive coronary artery disease that does not require invasive angiography.

Regarding his cardiovascular risk factors, he is an ex-smoker having quit 20 years ago, is non-diabetic with an HbA1c of 39 mmol/mol, has treated hypertension, and has suboptimally controlled hypercholesterolaemia for secondary prevention with an LDL of 2.8 mmol/L. Family history is notable for a paternal myocardial infarction at age 62, maternal hypertension, and a brother who suffered an ischaemic stroke at age 68.

Additional past medical history includes mild gastro-oesophageal reflux disease and benign prostatic hyperplasia.

On examination today, HR was 68 bpm regular, BP 132/78 mmHg, and O2 sats 98% on room air. JVP was not elevated, heart sounds were normal with a soft pansystolic murmur at the apex, carotid arteries had normal upstrokes without bruits, chest was clear to auscultation, and there was no peripheral oedema.

In conclusion, Arthur has newly diagnosed paroxysmal atrial fibrillation, which is the likely cause of his recent TIA, alongside mild non-obstructive coronary artery disease. Repeat lipid profile and LFTs should be checked by the GP in 3 months. We have commenced apixaban 5 mg PO BD, stopped clopidogrel 75 mg PO OD, commenced bisoprolol 2.5 mg PO OD, and increased atorvastatin to 80 mg PO ON. I have counselled him on the bleeding risks associated with anticoagulation, advised on lifestyle modifications, and arranged a follow-up appointment in the cardiology clinic in 6 months.