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Warrick is a practicing cardiologist an author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love.
Hi, I’m Dr. Warrick and I’d like to welcome you to my consulting room. Today I’d like to talk to a patient who has atrial fibrillation. Peter is a 65-year-old man who I literally saw just today, and his type of atrial fibrillation was the sort that was found completely incidentally. About a week or so ago, Peter was lining up for a routine colonoscopy which is a check of his lower bowel to see if there was any evidence of malignancy. During that examination while the anesthetist was looking after him, the patient was found to have an irregular heart rate.
The ECG and subsequent monitoring confirmed that he was in atrial fibrillation. Turns out the patient had no clue he was in atrial fibrillation – he had nothing in the way of symptoms and this is not entirely uncommon. A number of people walk around with what we would call asymptomatic atrial fibrillation. When I spoke with the patient, it turns out that he saw his GP probably three months ago and his blood pressure and pulse were checked then. Everything apparently was okay at that stage. This would probably suggest that Peter has gone into atrial fibrillation in that intervening period of time.
Peter’s other health includes a little bit of hypertension for which he was on therapy. He also has a bit of central adiposity and doesn’t exercise a lot and central adiposity just means the weight you put around your belly preferentially. This can be a marker of prediabetes and it is worth keeping in mind.
When we look at Peter’s risk of a stroke on that CHAD Vasc score, he had a score of 2. He scored one for age and one for hypertension. But in the back of my mind I would have added an extra score for prediabetes. With a score of 2, his risk of stroke is considered mild to moderate and the indications from that CHAD Vasc score are that he should be on full anticoagulation.
I commenced him on full anticoagulation from the consultation today. We also had some other information available. We had a 24-hour heart rate monitor, and this showed us that in the asymptomatic state on average this patient’s heart was beating at nearly 100 beats a minute. It went up as high as 180 beats a minute at times of exertion. For a gentleman who is in his mid-60s, that’s a very fast heartbeat and I must admit I was quite surprised that he was asymptomatic. With that information, one of the next things I did was to add in a drug to try and slow that heartbeat down. Because if we can do that I’m pretty sure we’ll give him a little bit more puff because it will allow his heart to work a bit better.
A heart that’s revving so fast just doesn’t fill properly and therefore doesn’t pump properly and so patients will almost invariably describe some shortness of breath in that situation. The other information that I had available was an ultrasound of his heart and this is a very important test to allow us further planning and certainly to rule in or rule out whether there is any structural abnormality, particularly around the mitral valve, which is the valve that controls blood flow out of the left atrium. Essentially Peter’s structure of the heart and function of the heart was relatively normal, but I focused in on this occasion on this side of his atria. It turns out his atria were mildly to moderately dilated not moderately not moderately to extensively, but they were dilated.
At this stage, my plan is to bring Peter back with full anticoagulation for...