Abstract
Presenting features
A 71-year-old African American woman with a history of rheumatic heart disease was
admitted with worsening dyspnea. Her past medical history was notable for chronic
renal insufficiency and atrial fibrillation. Her medications included diltiazem and
warfarin. Digoxin was added within the past month to improve rate control. In the
2 weeks leading up to admission, she experienced progressive dyspnea on exertion.
Initially, she had difficulty ambulating, but by the day of admission she was breathless
at rest. She also complained of generalized fatigue and a loss of appetite. She denied
any fevers, chills, visual disturbances, nausea, vomiting, palpitations, syncope,
or chest discomfort.
The patient was afebrile on presentation. Her pulse was irregular at a rate of 95
to 105 beats per minute, her blood pressure was 135/80 mm Hg, and her jugular veins
were distended to more than 15 cm above the sternal angle. Laboratory values were
notable for the following: serum creatinine, 3.7 mg/dL; potassium, 3.9 mEq/L; magnesium,
2.7 mg/dL; international normalized ratio, 1.2; and serum digoxin, 2.2 ng/mL. She
was placed on a cardiac monitor, which showed atrial fibrillation with a rapid ventricular
response and frequent premature ventricular depolarizations (Figure 1). Intermittently, she developed a wide-complex tachycardia at a rate of 150 beats
per minute (Figure 2). However, she was asymptomatic and hemodynamically stable during these episodes.
What is the diagnosis?
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Article info
Identification
Copyright
© 2003 Excerpta Medica Inc. Published by Elsevier Inc. All rights reserved.
