Concerning Regularity

Sina Jamé, MD and Mary Jamé, MD

December 15, 2016

A 90-year-old gentleman with a history of heart failure from ischemic dilated cardiomyopathy with reduced systolic function, paroxysmal atrial fibrillation, and stage II CKD presented to his outpatient provider with shortness of breath. The patient reported progressively worsening dyspnea on exertion, orthopnea, and weight gain of three weeks duration. Medications were notable for amiodarone and recent initiation of carvedilol. At rest, the patient had a heart rate of 47 bpm and an oxygen saturation of 92%; with ambulation, his heart rate increased to 74 bpm and oxygen saturation dropped to 84%. On examination, jugular venous pressure was 16 cm of water; bilateral crackles and worsening bilateral pitting edema were also present. Given the bradycardia noted on examination, an ECG was obtained (Figure 1).

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References:
1. Urbach JR, Grauman JJ, Straus SH. Quantitative Methods for the Recognition of Atrioventricular Junctional Rhythms in Atrial Fibrillation. Circulation. 1969; 39: 803-817.
2. Kojic EM, Hardarson T, Sigfusson N, Sigvaldason H. The prevalence and prognosis of third-degree atrioventricular conduction block: the Reykjavik study. J Intern Med. 1999 Jul;246(1):81-6.
3. Epstein AE et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. Circulation. 2008 May 27;117(21):e350-408.

Author Information:
Drs. Sina and Mary Jamé are PRIME Internal Medicine residents at the University of California, San Francisco.