Functional situation:
Physical status: IABVD.

Current history:
84-year-old woman with no PA of interest presented with progressive dyspnoea of more than 2 weeks' evolution until minimal effort, orthopnoea and oedema in the lower limbs.
She reported dubious palpitations for several days but denied angina, syncope or other symptoms.
No recent infections, no changes in medication or any other cause justifying the decompensation.

Physical examination:
Admission: BP: 138/90 mmHg HR: 166 bpm. Ta: 36.2 C. SatO2: 95 % basal BEG. IY. ACP: Arrhythmic without murmurs; MVC with crackles up to midfields. MMII: oedema up to middle third, no signs of DVT.

At discharge: BP: 100/70 mmHg HR: 80 bpm. ACP: Arrhythmic without murmurs; CVM with crackles in right base. MMII: no oedema or signs of DVT.

Summary of complementary tests:

Laboratory:
Urgent CBC 03/09/2021 21:16: Red cells 4,770,000/pL, Hb 14.1 g/dL, Hto 43%, MCV 90.1 fL, MCH 29.5 pg, Leukocytes 7140/pL [N 4180, L 2150, M 380, E 250, B 40, LUC 150, N/L 1.94}, Platelets 156,000/4, PWV 12.8 fL, PT 12 s / 77%, INR 1.1, Fibrinogen 335 mg/dL, TTPa 24.7 s / ratio 0.92, Glycaemia 105 mg/dL, Creatinine 0.82 mg/dL, Filtrate 66 mL/min, Urea 55 mg/dL, Na+ 139 mmol/L, K+ 4.6 mmol/L, Cl- 105 mmol/L, ASAT 77 IU/L, ALAT 85 IU/L, LDH 270 U1/L, GGT 120 IU/L, BRT 0.87 mg/dL, BRD 0.26 mg/dL, BRI 0.61 mg/dL, NT-proBNP 3145 pg/mL, PCR 3.7 mg/L

CBC delayed 06/09/2021 08:30: Red cells 4,720,000/11, Hb 13.8 g/dL, Hto 42.3%, MCV 89.6 fL, MCH 29.3 pg, Leukocytes 7410/pL [N 3790, L 2660, M 470, E 300, B 40, LUC 140, N/L 1.42], Platelets 175,000/pL, PWV 12.8 fL, PT 13 s / 65%, INR 1.2, Fibrinogen 361 mg/dL, TTPa 26.6 s / ratio 0.99, Blood glucose 99 mg/dL, HbA1C 5.4%, Total cholesterol 160 mg/dL, HDL 58 mg/dL, non-HDL 102 mg/dL, LDLc 88 mg/dL, TG 71 mg/dL, Creatinine 1.16 mg/dL, Filtrate 43 mL/min, Urate 7.7 mg/dL, Na+ 140 mmol/L, K+ 3.9 mmol/L, Cl- 100 mmol/L, ASAT 38 Ul/L, ALAT 63 Ul/L, FAIc 102 Ul/L, GGT 96 Ul/L, BRT 0.74 mg/dL, CPK 46 Ul/L, Proteins 6.2 g/dL, CRP 3.1 mg/L, Iron 45 pg/dL, Transferrin 199 mg/dL, CTTH 281 pg/dL, IST 16%, Ferritin 121 ng/mL, TSH 3.16 pUl/mL

CBC at discharge: 09/09/2021 08:32:22: Hemoglobin 13.4 g/dL (11.8 - 15.8), Hematocrit 41.1 % (35 - 45), M.C.V. 91.1 fL (80 - 101), Leukocytes 8.58 x10e3/pL (3.6 - 10.5), Platelets 154 x10e3/pL (150 - 370), INR 1.1 (0.8 - 1.2), SERUM GLUCOSE 107 mg/dL (74 - 106), SERUM CREATININE 0.72 mg/dL (0.5 - 1.1), GLOMERULAR FILTERING (CKD-EPI) 77 mL/min/1.73m2 (45 - 999999), SERUM SODIUM 134 mmol/L (136 - 145), SERUM POTASSIUM 4.2 mmol/L (3.5 - 5.1), NT-proBNP 4177 pg/mL (0 - 450)


Image:
Chest CXR 03/08/21: increased CTI, marked vascular redistribution without clear pleural effusion.
No consolidation

Echocardioscopy 03/08/21: Performed in AF at about 130-140Ipm, LV not dilated mild-mod dysfunctioning. RV normal. Moderate-severe TR with no other valvular heart disease. No effusion. Biauricular dilatation. Dilated vena cava with hardly any respiratory fields. Echocardiogram 06/09/21: study performed in AF at 100-130 Ipm. Left ventricle not dilated, mild hypertrophy, with slightly depressed global systolic function. LVEF BP 47% with global hypokinesia and septal motion related to right overload. Mitral insufficiency at least moderate. Moderate dilatation of both atria. Slightly dilated right ventricle with moderate dysfunction. Moderate to severe tricuspid insufficiency due to dilatation of the annulus. Estimated PSAP around 45-50 mmHg. Inferior vena cava not dilated and with physiological inspiratory collapse. No pericardial effusion.

Other tests:
ECG urg 03/08/21: AF with RVR at 120 Ipm, normal axis, narrow QRS without repolarisation alterations.

ECG 08/09/21: AF with RVR at 108 Ipm, normal axis, narrow QRS without repolarization alterations.

PCR COVID 03/08/21: negative

Evolution and comments:
Admitted for a first episode of HF in the context of AF with rapid ventricular response.
Rapid improvement with intravenous diuretic treatment. HF control (bisoprolol and digoxin at low doses) was chosen as the atria were dilated and he presented moderate-severe TR as well as at least moderate 1M. Medical treatment was adjusted and anticoagulation with rivaroxaban was started, and the patient was referred for follow-up. 1ECA was not prescribed due to a tendency to hypotension.

Main diagnosis:
First episode of HF. Atrial fibrillation with rapid RV. CHADS-Vasc 4. Moderate to severe TR, at least moderate 1M and biauricular dilatation. Slightly depressed LVEF (47%).

Treatment:

Drugs:
-Xarelto 20 mg: 1 tablet at dinner.
-Bisoprolol 5 mg: 1 tablet at breakfast and dinner.
-Digoxin 0.25 mg: 1/2 tablet daily.
-Jardiance 10 mg: 1 tablet at breakfast.
-Elecor (eplerenone) 25 mg: 1 tablet at breakfast.
-Seguril 1 tablet at breakfast for one week and discontinue. In case of oedema, rapid weight gain or dyspnoea, you can temporarily take 2-3 tablets daily.

Continue with home pharmacological treatment: CITALOPRAM 10 MG 1-0-0, OMEPRAZOL 20 MG 0-1-0, NOLOTIL 575MG 1-1-1 if severe pain, MASTICAL D 500 MG/ 800 UI 0-0-1 and PARACETAMOL 1000 MG 1-0-1

Other Recommendations:
Review in Primary Care and Cardiology consultations (appointment attached).


MEDICATION SHEET

DRUGS

PARACETAMOL 1000 MG 40 TABLETS
Breakfast 1
Lunch
Dinner 1
At Bedtime
Start Date 02/10/12
End Date CRONIC

CITALOPRAM 10 MG 28 TABLETS
Breakfast 1
Lunch
Dinner
At Bedtime
Start Date 06/13/19
End Date CRONIC

MASTICAL D 500 MG/ 800 UI TABLETS
Breakfast
Lunch
Dinner 1
At Bedtime
Start Date 28/04/15
End Date CRONIC

OMEPRAZOLE 20 MG 28 CAPSULES
Breakfast
Lunch 1
Dinner
At Bedtime
Start Date 15/04/16
End Date CRONIC

NOLOTIL 575MG 20 CAPSULES
Units: CAPSULE, Route: ORAL
Breakfast 1
Lunch 1
Dinner 1
At Bedtime
Start Date 12/13/16
End Date CHRONIC IF SEVERE PAIN

XARELTO 20 MG FILM-COATED TABLETS WITH
Units: PILL, Route: ORAL
Breakfast
Lunch
Dinner 1
At Bedtime
Start Date 09/09/21
End Date CRONIC

BISOPROLOL 5 MG 60 TABLETS
Units: PILL, Route: ORAL
Breakfast 1
Lunch
Dinner 1
At Bedtime
Start Date 09/09/21
End Date CRONIC

DIGOXIN KERN PHARMA 0,25MG 50 TABLETS
Units: PILL, Route: ORAL
Breakfast 0,5
Lunch
Dinner
At Bedtime
Start Date 09/09/21
End Date CRONIC

JARDIANCE 10MG FILM-COATED TABLETS WITH
Units: POCKET, Route: ORAL
Breakfast 1
Lunch
Dinner
At Bedtime
Start Date 09/09/21
End Date CRONIC

EPLERENONE 25 MG 30 TABLETS
Units: PILL, Route: ORAL
Breakfast 1
Lunch
Dinner
At Bedtime
Start Date 09/09/21
End Date CRONIC

SEGURIL 40MG 30 TABLETS
Units: PILL, Route: ORAL
Breakfast 1
Lunch
Dinner
At Bedtime
Start Date 09/09/21
End Date CRONIC
