Cardiology Specialist Assessment Letter for GP

Dr Alistair Vance Oakwood Medical Centre 14 High Street Guildford GU1 3AA

Dear Dr Vance

Re: Arthur Pendelton, DOB: 12/05/1956

Thank you for referring Mr Arthur Pendelton to the cardiology outpatient clinic for specialist evaluation.

Mr Pendelton is a 69-year-old retired civil engineer who presents with a six-month history of recurrent, unprovoked palpitations and transient episodes of lightheadedness.

His symptoms began gradually in October 2025, initially occurring once every two weeks, before increasing in frequency to two or three times per week over the past month. He describes the episodes as a sudden, rapid, irregular fluttering sensation in the central chest, lasting between 15 minutes and two hours, accompanied by mild exertional dyspnoea and presyncope, though he has never experienced complete syncope or chest pain. He has a past medical history of essential hypertension, type 2 diabetes mellitus, and a transient ischaemic attack in 2023, for which he was reviewed by the neurology service. He is a lifelong non-smoker, consumes approximately four units of alcohol per week, and notes a family history of ischaemic heart disease in his father.

On examination today, Mr Pendelton appeared comfortable at rest with a body mass index of 27.4 kg/m². His radial pulse was irregularly irregular at a rate of 88 beats per minute, and his blood pressure was elevated at 146/84 mmHg. The jugular venous pressure was not elevated, and carotid auscultation revealed no bruits. Precordial palpation demonstrated an undisplaced apex beat, and auscultation revealed normal first and second heart sounds with no added murmurs or rubs. His chest was clear to auscultation bilaterally, and there was no peripheral pitting oedema.

Mr Pendelton's clinical presentation and resting electrocardiographic findings confirm a diagnosis of symptomatic paroxysmal atrial fibrillation. Given his age, hypertension, diabetes, and prior cerebrovascular event, his calculated CHA2DS2-VASc score is 5, which confers a significant annual risk of thromboembolism. We discussed the rationale for formal oral anticoagulation alongside rate control therapy, and Mr Pendelton is keen to commence treatment to mitigate his stroke risk and improve his day-to-day symptom burden.

Diagnoses

1. Paroxysmal atrial fibrillation (CHA2DS2-VASc score 5)
2. Essential hypertension
3. Type 2 diabetes mellitus
4. Previous transient ischaemic attack (2023)

Investigations

1. Magnetic resonance imaging of the brain (14/08/2023): No acute infarction, mild chronic microvascular ischaemic changes.
2. Venous blood panel (02/04/2026): Haemoglobin 142 g/L, eGFR 68 mL/min/1.73m², HbA1c 51 mmol/mol, TSH 1.8 mU/L.
3. 24-hour ambulatory electrocardiogram (05/04/2026): Sinus rhythm with three runs of paroxysmal atrial fibrillation lasting up to 45 minutes, maximum ventricular rate 134 beats per minute.
4. 12-lead electrocardiogram (15/04/2026): Atrial fibrillation with a ventricular rate of 86 beats per minute, normal axis, no acute ST-T wave changes.

Medications

1. Apixaban 5 mg PO BID
2. Bisoprolol 2.5 mg to 5 mg PO OD
3. Ramipril 10 mg PO OD
4. Metformin 1,000 mg PO BID
5. Atorvastatin 40 mg PO ON
6. Clopidogrel 75 mg PO OD (Discontinued)

Note: Clopidogrel 75 mg PO OD was discontinued on 15/04/2026 prior to the initiation of apixaban to reduce bleeding risk.

Suggested Management Plan

1. Mr Pendelton has been advised to eliminate caffeine intake, maintain modest alcohol consumption below 14 units per week, and engage in regular moderate-intensity aerobic exercise as tolerated.
2. A transthoracic echocardiogram has been requested to assess left ventricular systolic function and left atrial dimensions, and a repeat clinic review is scheduled in three months.
3. ACTIONS FOR SECRETARY: Book an outpatient transthoracic echocardiogram within six weeks and arrange a follow-up cardiology appointment in three months.

We have initiated apixaban 5 mg PO BID for stroke prophylaxis and concurrently discontinued his clopidogrel 75 mg PO OD, counselling Mr Pendelton thoroughly on the associated risk of bruising and bleeding, and advising him to seek urgent medical attention in the event of head trauma or prolonged bleeding. To achieve optimal rate control, he will commence bisoprolol 2.5 mg PO OD, which you may uptitrate to 5 mg PO OD in primary care after two weeks if his resting heart rate remains above 80 beats per minute and his blood pressure allows. I will review him in the cardiology clinic in three months following completion of his transthoracic echocardiogram to evaluate his symptomatic response and consider rhythm control strategies if he remains symptomatic.

"Yours sincerely,"

Dr Eleanor Vance-Sterling Consultant Cardiologist