Cardiology Consultation Note

I was pleased to see Sipho Ndlovu today. He is a pleasant 64-year-old male referred for cardiovascular evaluation.

Cardiac Risk Factors

Elevated BMI present (31.2 kg/m²).

Hypertension present.

Dyslipidemia present.

Type 2 diabetes mellitus present.

Ex-smoker with a 30 pack-year history (1 pack per day for 30 years).

Quit smoking in 2012 (remote cessation).

Positive family history of premature atherosclerotic disease: father suffered a fatal MI at age 51.

Cardiac History

Established history of HFrEF, paroxysmal atrial fibrillation, prior symptomatic Mobitz II AV block, mild-to-moderate calcific aortic stenosis, and ischaemic heart disease (CAD).

HFrEF (LVEF 38%), dual-chamber ICD (Medtronic Evera MRI XT DR) implanted 14/06/2021.

Paroxysmal atrial fibrillation: underwent successful electrical cardioversion on 10/11/2020 and pulmonary vein isolation (PVI) cryoablation on 22/03/2022.

Prior dual-chamber pacemaker (Medtronic Azure XT DR) implanted 12/02/2019 for symptomatic Mobitz type II second-degree AV block (subsequently upgraded to ICD in 2021).

Mild-to-moderate calcific aortic stenosis (diagnosed 2021, managed conservatively without intervention to date).

CAD: Coronary angiography (15/05/2018) demonstrated 85% mid-LAD stenosis and 70% obtuse marginal (OM1) stenosis; treated with PCI and 1 x drug-eluting stent (DES) to mid-LAD on 15/05/2018.

Other Medical History

Stage 3a chronic kidney disease (2020), GORD (2015), and laparoscopic cholecystectomy (2014).

Current Medications

Antithrombotics: apixaban (Eliquis®) 5 mg PO BID, acetylsalicylic acid (aspirin, Disprin®) 81 mg PO daily. Antihypertensives / Heart failure therapies: sacubitril/valsartan (Entresto®) 49/51 mg PO BID, bisoprolol (Concor®) 5 mg PO daily, dapagliflozin (Forxiga®) 10 mg PO daily, spironolactone (Aldactone®) 12.5 mg PO daily (half of a 25 mg tablet), furosemide (Lasix®) 40 mg PO daily. Lipid-lowering therapies: rosuvastatin (Crestor®) 20 mg PO nocte. Other medications: metformin (Glucophage®) 1,000 mg PO BID, pantoprazole (Pantoloc®) 40 mg PO daily.

Allergies and Intolerances

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

Social History

Mr Ndlovu resides in a single-storey house in Johannesburg with his wife; they have two adult children. He is a retired high school teacher with comprehensive medical aid coverage (Discovery Health). Smoking history as above. He consumes 2 units of red wine per week on weekends and denies recreational or illicit drug use. He remains fully independent with all ADLs and IADLs.

History

Mr Ndlovu presents for review of worsening exertional dyspnoea (NYHA Class II–III) and intermittent central chest tightness over the past 4 weeks. Symptoms are triggered by walking approximately 150 metres on a slight incline and resolve within 5 minutes of rest. He reports two episodes of brief palpitations last week lasting 10 minutes each. He notes mild bilateral ankle swelling by the evening. He denies orthopnoea, PND, presyncope, syncope, or rested chest pain.

“Review of systems was otherwise non-contributory.”

Physical Examination

BP 134/78 mmHg, HR 68 bpm (regular), SpO2 96 % on room air. JVP is elevated at 4 cm above the sternal angle. Well-healed left infraclavicular device scar noted. Precordial impulse is mildly displaced laterally; no thrills. S1 and S2 are dual with a grade 2/6 ejection systolic murmur loudest at the right upper sternal border, no radiation to the carotids, and no S3 or S4. Bibasal fine inspiratory crackles are audible on auscultation. Trace bilateral pitting pedal oedema is present to the ankles.

Investigations

Labs (18/05/2025): Hb 13.8 g/dL, WCC 6.4 x 10^9/L, Plt 215 x 10^9/L, Na 138 mmol/L, K 4.6 mmol/L, Cr 118 µmol/L, eGFR 54 mL/min/1.73m², hs-Troponin T 16 ng/L, NT-proBNP 1,450 pg/mL, HbA1c 7.1 %, Total Cholesterol 3.6 mmol/L, LDL-C 1.6 mmol/L, HDL-C 1.1 mmol/L, Triglycerides 1.9 mmol/L.

ECG (20/05/2025): Atrial-sensed ventricular-paced rhythm at 68 bpm, QRS duration 140 ms (LBBB morphology secondary to RV pacing), no acute ST-T wave changes.

Transthoracic Echocardiogram (12/04/2025): Mildly dilated LV with LVEF 38%, anterior wall hypokinesis, mild-to-moderate calcific aortic stenosis (peak velocity 2.8 m/s, mean gradient 18 mmHg, AVA 1.3 cm²), mild functional MR, normal RV systolic function, RVSP 36 mmHg.

Exercise Stress Test (10/04/2018): Positive for clinically and electrically inducible ischaemia at 6.5 METs (2 mm horizontal ST depression in V4–V6 with chest tightness).

24-Hour Holter Monitor (05/04/2025): Predominantly atrial-sensed ventricular-paced rhythm (average HR 66 bpm), 4% premature ventricular contractions, no sustained tachyarrhythmias detected.

ICD Interrogation (20/05/2025): Battery longevity 5.5 years remaining, normal lead impedances and sensing/pacing thresholds, AS-VP 94%, AS-VS 6%, two short episodes of atrial high-rate episodes (AHREs) lasting < 15 minutes on 14/05/2025, zero VT/VF episodes or therapies delivered.

Technetium-99m MIBI Myocardial Perfusion Scan (14/05/2025): Fixed small anterior wall defect (scar) with mild reversible ischaemia in the lateral wall (OM1 territory, ~8% myocardium), calculated LVEF 37%.

CT Coronary Angiogram (02/05/2018): Agatston calcium score 640; severe mid-LAD plaque and moderate-to-severe OM1 stenosis.

Cardiac MRI (18/05/2021): LVEF 36%, subendocardial late gadolinium enhancement (LGE) in the mid-anterior territory (50% transmurality) consistent with prior LAD territory infarction; no LV thrombus.

Chest X-Ray (18/05/2025): Mild cardiomegaly, left-sided dual-chamber ICD leads in situ, mild upper lobe pulmonary venous diversion, no pleural effusions.

Summary

Sipho Ndlovu is a pleasant 64-year-old male who attended today for cardiovascular evaluation.

His cardiac risk factors include elevated BMI, hypertension, dyslipidemia, T2DM, a 30 pack-year remote smoking history, and a family history of premature CAD.

He presents with a 4-week history of NYHA Class II–III exertional dyspnoea, mild angina, and mild fluid overload. Recent myocardial perfusion imaging demonstrates mild lateral wall reversible ischaemia (OM1 territory), while labs show an elevated NT-proBNP (1,450 pg/mL) and TTE confirms stable HFrEF (LVEF 38%) with mild-to-moderate aortic stenosis.

Assessment/Plan

#1 Mildly decompensated HFrEF (LVEF 38%)

Assessment: Mild volume overload likely precipitated by dietary indiscretion and suboptimal GDMT dosing, compounded by high right ventricular pacing burden (94%).

Plan: Increase furosemide (Lasix®) to 80 mg PO daily for 7 days, then revert to 40 mg PO daily. Uptitrate sacubitril/valsartan (Entresto®) to 97/103 mg PO BID as BP tolerates. Check U&E and creatinine in 10 days. Discussed potential upgrade to CRT-D if symptoms persist despite optimal medical therapy given 94% RV pacing burden.

#2 Stable Angina / Ischaemic Heart Disease

Assessment: CCS Class II angina with mild lateral wall reversible ischaemia (~8% burden in OM1 territory) on recent MIBI scan.

Plan: Optimise anti-anginal therapy before considering repeat invasive angiography given small ischaemic burden. Initiate isosorbide mononitrate (Imdur®) 30 mg PO daily and uptitrate bisoprolol (Concor®) to 7.5 mg PO daily. Stop acetylsalicylic acid (aspirin, Disprin®) 81 mg PO daily and continue apixaban monotherapy to reduce bleeding risk, as he is > 1 year post-PCI.

#3 Paroxysmal Atrial Fibrillation

Assessment: Well-controlled post-PVI with only brief, self-terminating AHREs noted on ICD check.

Plan: Continue apixaban (Eliquis®) 5 mg PO BID and current rate/rhythm control via beta-blockade.

Follow-Up

Follow-up is scheduled in 3 months with a repeat TTE and U&E, or earlier if clinically required.

“I appreciate the opportunity to contribute to Sipho Ndlovu’s care. Please contact me directly with any questions or concerns.”