Cardiology Consult

I was pleased to see Arthur Pendelton today. He is a pleasant 68-year-old male referred for cardiac evaluation.

Cardiac Risk Factors

Increased BMI: Yes (BMI 31.2 kg/m²)

Hypertension: Yes

Dyslipidemia: Yes

Diabetes mellitus: Yes (T2DM)

Smoker: 30 pack-years (smoked 1 pack per day for 30 years)

Ex-smoker: Quit in 2010 (remote cessation)

Family history of atherosclerotic disease in first-degree relatives: Positive; father had MI at age 52.

Cardiac History

HFrEF, persistent atrial fibrillation, Mobitz II AV block with dual-chamber pacemaker, severe aortic stenosis status post TAVR, CAD status post PCI.

HFrEF (LVEF 35%). Primary prevention ICD implanted 14/05/2021 (Medtronic Evera MRI XT DR).

Persistent AF. DCCV performed 10/11/2019; pulmonary vein isolation ablation performed 22/08/2020.

History of Mobitz II AV block. Dual-chamber pacemaker implanted 12/03/2018 (Boston Scientific Accolade MRI), subsequently upgraded to CRT-D/ICD on 14/05/2021.

Severe calcific aortic stenosis; underwent bioprosthetic TAVR (Edwards SAPIEN 3) on 04/02/2022.

CAD: Coronary angiogram on 18/06/2017 demonstrated 85% mid-LAD stenosis and 50% circumflex disease; underwent PCI with 1 DES to mid-LAD on 18/06/2017.

Other Medical History

GERD (2012), osteoarthritis of the knees (2015), laparoscopic cholecystectomy (2016), stage 3a CKD (2019).

Current Medications

Antithrombotic Therapy: apixaban (Eliquis®) 5 mg PO BID, aspirin 81 mg PO daily

Antihypertensives: metoprolol succinate (Toprol-XL®) 50 mg PO daily (usual recommended dose 100-200 mg daily)

Heart Failure Medications: sacubitril/valsartan (Entresto®) 49/51 mg PO BID (usual recommended target dose 97/103 mg BID), dapagliflozin (Farxiga®) 10 mg PO daily, spironolactone (Aldactone®) 25 mg PO daily, furosemide (Lasix®) 40 mg PO daily

Lipid Lowering Medications: rosuvastatin (Crestor®) 20 mg PO daily, ezetimibe (Zetia®) 10 mg PO daily

pantoprazole (Protonix®) 40 mg PO daily, metformin (Glucophage®) 500 mg PO BID (usual recommended dose 1,000 mg BID)

Allergies And Intolerances

Penicillin (maculopapular rash), lisinopril (dry cough).

Social History

Lives in a single-level house with his wife and has 2 adult children. He is a retired accountant with comprehensive private health and prescription drug coverage. Independent in all ADLs and IADLs. Smoking history as above. Drinks 2 glasses of wine per week; denies illicit or recreational drug use.

History

The patient presents for routine follow-up of HFrEF, CAD, and AF, reporting progressive exertional dyspnea over the past 3 weeks. He notes shortness of breath after walking 2 blocks on level ground or climbing 1 flight of stairs, which is a decline from his baseline of walking 1 mile daily without limitation. He reports mild bilateral ankle swelling by the evening and 2-pillow orthopnea, but denies paroxysmal nocturnal dyspnea, chest pain, pressure, palpitations, presyncope, or syncope. He has reduced his regular 30-minute morning walks due to fatigue.

"The remainder of the review of systems is non-contributory."

Physical Examination

BP 134/78 mmHg, HR 68 bpm, SpO2 96% on room air. The precordium was unremarkable, without notable heaves, thrills, or pulsations; heart sounds were normal, with no important murmurs, rubs, or gallops. Bibasilar crackles were auscultated at the lung bases bilaterally. There was 1+ pitting oedema bilaterally to the mid-shins. JVP was elevated at 4 cm above the sternal angle.

Investigations

Laboratory investigations: (10/10/2023): Hb 13.4 g/dL, WBC 6,800 /µL, Plt 210,000 /µL, Na 138 mmol/L, K 4.6 mmol/L, Cr 1.35 mg/dL, eGFR 54 mL/min/1.73m², hs-troponin I 14 ng/L, NT-proBNP 1,850 pg/mL, HbA1c 6.8%, Total Cholesterol 145 mg/dL, LDL 62 mg/dL, HDL 42 mg/dL, TG 205 mg/dL, TSH 2.1 mIU/L.

ECGs: (12/10/2023): Atrial-sensed ventricular-paced rhythm at 68 bpm, QRS duration 138 ms, no acute ST-T wave changes.

Echocardiograms: (05/10/2023): LVEF 35-40%, global LV hypokinesis, well-seated aortic bioprosthesis with mean gradient 11 mmHg and no paravalvular leak, mild mitral regurgitation, RVSP 42 mmHg.

Stress tests: (12/04/2021): Pharmacologic nuclear stress test negative for inducible ischemia.

Holter monitors: (15/07/2020): Persistent atrial fibrillation with controlled ventricular response, average HR 74 bpm, no pauses > 2.5 seconds.

Device interrogations: (12/10/2023): Medtronic CRT-D interrogation shows 99% biventricular pacing, persistent AF, 0 VT/VF episodes, battery longevity 5.2 years, normal lead impedances and thresholds.

Cardiac perfusion imaging: (12/04/2021): Fixed small apical defect consistent with prior infarct, no reversible perfusion defects, LVEF 38%.

Cardiac CT: (10/01/2022): TAVR protocol CTA showed severe aortic valve calcification, annular area 480 mm², patent proximal coronaries, adequate iliofemoral access.

Cardiac MRI: (02/03/2021): Mid-wall late gadolinium enhancement in the interventricular septum and subendocardial scar in the mid-anterior wall, LVEF 36%.

Other investigations: (10/10/2023): CXR showed mild cardiomegaly, stable sternal/device hardware, mild pulmonary venous congestion, no pleural effusions.

Summary

Arthur Pendelton is a pleasant 68-year-old male seen today for cardiac evaluation. Cardiac risk factors include increased BMI, hypertension, dyslipidemia, diabetes mellitus, remote smoking history, and a positive family history of premature CAD. He has a complex cardiac history including HFrEF (LVEF 35-40%) with CRT-D, persistent AF on anticoagulation, prior TAVR for severe AS, and CAD s/p LAD PCI, presenting today with NYHA class III dyspnea and volume overload. Recent labs show elevated NT-proBNP at 1,850 pg/mL with stable renal function, TTE confirms stable LVEF 35-40% and normal TAVR prosthesis function, and CRT-D interrogation confirms 99% biventricular pacing without tachyarrhythmias.

Assessment/Plan

#1 HFrEF (LVEF 35-40%)

Assessment: Mild acute-on-chronic decompensated heart failure (NYHA Class III), likely secondary to dietary sodium indiscretion and sub-target GDMT dosing.

Plan: Increase furosemide (Lasix®) to 80 mg PO daily for 5 days, then return to 40 mg PO daily to achieve euvolemia. Once euvolemic next week, up-titrate sacubitril/valsartan (Entresto®) to 97/103 mg PO BID as BP tolerates. Check BMP in 7 days to monitor renal function and potassium. Counselled on strict < 2,000 mg/day sodium restriction, 2 L/day fluid restriction, and daily morning weight monitoring (instructed to call clinic if weight increases by > 3 lbs in 2 days).

#2 Persistent Atrial Fibrillation

Assessment: Rate-controlled via AV nodal blockade and biventricular pacing; appropriately anticoagulated.

Plan: Continue apixaban (Eliquis®) 5 mg PO BID and metoprolol succinate (Toprol-XL®) 50 mg PO daily. Monitor renal function annually.

#3 Coronary Artery Disease and Severe Aortic Stenosis s/p TAVR

Assessment: Stable; no anginal symptoms and well-functioning bioprosthetic aortic valve on recent TTE.

Plan: Continue rosuvastatin (Crestor®) 20 mg PO daily and ezetimibe (Zetia®) 10 mg PO daily as LDL is at goal (< 70 mg/dL). Discontinue aspirin 81 mg PO daily to reduce bleeding risk, given he is > 1 year out from PCI/TAVR and remains on therapeutic apixaban.

Follow-Up

Repeat electrolyte and renal panel in 1 week, with clinic follow-up in 4 weeks to reassess volume status and GDMT titration.

"Thank you for the opportunity to participate in Arthur Pendelton's care. Please contact me directly with any questions or concerns."