Cardiology Clinic Letter

Diagnosis

Paroxysmal atrial fibrillation (CHA2DS2-VASc score 3) Recent right middle cerebral artery territory transient ischaemic attack (14/04/2026) Essential hypertension Hypercholesterolaemia

Actions for GP

Please initiate apixaban 5 mg orally twice daily for stroke prophylaxis. Please increase bisoprolol from 2.5 mg to 5 mg orally once daily for improved ventricular rate control. Please check baseline renal function and full blood count prior to commencing anticoagulation.

Plan

• Start a blood-thinning medicine called apixaban at a dose of 5 mg taken by mouth twice a day to reduce your risk of future strokes.
• Increase your heart rate medicine, bisoprolol, from 2.5 mg to 5 mg taken by mouth once a day.
• Arrange a 7-day heart rhythm monitor to check how often your heart goes into an irregular rhythm and to make sure your heart rate is well controlled.
• Reduce your caffeine intake to one cup of coffee per day and keep your alcohol intake under 14 units per week.
• Review you again in the cardiology clinic in 3 months after your heart monitor test is complete.

Impression

This 68-year-old gentleman was referred by the stroke neurology team following a recent right middle cerebral artery territory transient ischaemic attack, during which telemetry captured paroxysmal atrial fibrillation. Today in clinic, he reports ongoing intermittent palpitations, though he is currently in sinus rhythm with borderline rate control. His transthoracic echocardiogram demonstrates mild left atrial dilatation with preserved biventricular systolic function and no significant valvular disease.

Given his recent cerebral ischaemic event and a CHA2DS2-VASc score of 3, formal oral anticoagulation is strongly indicated for secondary stroke prevention. His HAS-BLED score is 1, indicating a low bleeding risk. After discussing the risk-benefit profile, a decision was made to initiate a direct oral anticoagulant alongside up-titration of his beta-blocker therapy to optimise rate control and suppress symptomatic ectopy.

Medication

amlodipine 5 mg orally once daily, atorvastatin 40 mg orally once daily, bisoprolol 2.5 mg orally once daily, clopidogrel 75 mg orally once daily Stop clopidogrel 75 mg orally once daily. Start apixaban 5 mg orally twice daily. Increase bisoprolol to 5 mg orally once daily.

I was pleased to meet you in the cardiology clinic today following the referral from your neurologist. You came to see me because you had a mini-stroke on 14/04/2026, and the hospital heart monitors showed that you were having episodes of an irregular heart rhythm called atrial fibrillation. You told me that over the last two months, you have noticed a fluttering sensation in your chest about twice a week. These episodes start suddenly, last for roughly twenty minutes, and sometimes make you feel slightly lightheaded, though you have never fainted or had any chest pain or shortness of breath.

In terms of your medical background, you have been treated for high blood pressure and high cholesterol for the past five years. You have never had any previous heart procedures or heart attacks. You mentioned that your father had a stroke in his seventies. You are a retired schoolteacher living at home with your wife. You do not smoke, you drink about two glasses of wine at the weekend, and you enjoy walking your dog for thirty minutes every day, though you do drink four strong cups of coffee daily.

When I examined you today, your blood pressure was slightly raised at 138/84 mmHg and your pulse was regular at 78 beats per minute. Listening to your chest showed that your heart sounds were entirely normal and your lungs were clear, with no swelling in your ankles. Your heart tracing today showed a normal, regular rhythm. I also reviewed the ultrasound scan of your heart that was done while you were on the stroke ward, which showed that your heart muscle pumps strongly and your heart valves are working well, with only slight stretching of the top left chamber of your heart. Your recent blood tests showed normal kidney function, a normal blood count, and a normal thyroid level.

We had a detailed discussion about how to manage your irregular heart rhythm and protect you from having a full stroke in the future. Because atrial fibrillation can cause blood clots to form in the heart, I explained that taking a blood-thinning medicine is the most effective way to lower your stroke risk. We talked about the benefits of preventing a stroke versus the small risk of bruising or bleeding that comes with blood thinners. You felt that protecting yourself against another stroke was your top priority, so you were keen to switch from your current anti-clotting tablet, clopidogrel, to a stronger blood thinner called apixaban. We also agreed to slightly increase the dose of your bisoprolol tablet to help calm the fluttering sensations in your chest.

Going forward, your general practitioner will provide you with the new prescriptions for apixaban and the higher dose of bisoprolol; please remember to stop taking your clopidogrel on the exact day you start the apixaban. I have requested a 7-day wearable heart monitor for you, which will be sent out in the post so I can see how well the increased tablet dose is controlling your heart rhythm. In the meantime, I advised you to cut back on coffee, as caffeine can trigger heart fluttering. If you experience a racing heart that does not settle down after resting, chest pain, severe dizziness, or any signs of another mini-stroke such as facial weakness, arm weakness, or slurred speech, you must call 999 or go to your nearest emergency department immediately. I have arranged to see you again in my clinic in three months to review your heart monitor results.