Case 3:

An 81-year-old woman with longstanding history of heart disease and atrial fibrillation presents with progressive fatigue and exertional dyspnea over the past 4 months. Prior attempts at cardioversion 10 yrs ago were unsuccessful, and she refused surgery for her heart valve. Two months ago, she began to have trouble speaking, but this has improved.  Her high blood pressure had been poorly controlled, so her medications were adjusted 6 months ago. Metoprolol was making her tired. Amlodipine was added, and since then her bp has been ok.

    Prior medication:                 Current medication:
Digoxin                             Digoxin      
Metoprolol 50 mg BID        Metoprolol 25 mg bid/Amlodipine 10 mg
Aspirin 325 mg/day           Aspirin 325 mg/day
Metformin                      Metformin


Vitals:     Afebrile  HR  130-160, BP 150/86, RR 28

HEENT:    PERRLA, L facial droop

JVP:         To angle of jaw at 60 degrees

Lung:       Bilateral rales in the lower 1/3rd

Cor:                 rapid irregular S1S2S3,  PMI in anterior axillary line, 3/6 holosystolic     apical murmur radiating to the axilla

Abd:                Liver span 16cm

Ext:         Cool, 3+edema bilaterally


An echocardiogram showed severe left atrial enlargement, moderate to severe mitral regurgitation and an LVEF of 40%