RE-THINKING THE MANAGEMENT OF

ATRIAL FIBRILLATION

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Case study: atrial fibrillation

Kenneth “Ken” Henderson is a 67-year-old male who began feeling more fatigued than usual for approximately three weeks. Yesterday morning he noticed his heart was racing when he was walking to his car after work, although he did not notice any other symptoms at the time. When it did not resolve, he told his wife and she encouraged him to organise an appointment with you. Ken reports no chest pain and has not noticed his heart racing before.

Medical history

Chronic Kidney Disease (CKD)
  • Diagnosed 11 years ago. At his last review three months ago, his eGFR was 48 mL/min/1.72m2 and his ACR was 4.0 mg/mmol

Hypertension
  • A blood pressure of 165/90 mmHg was identified at the time CKD was diagnosed; this is thought to be the main contributor to Ken’s CKD
  • Antihypertensive treatment was initiated
  • The most recent blood pressure was 135/80 mmHg two months ago
  • No other known cardiovascular issues identified

Dyspepsia
  • Ken has experienced symptoms of dyspepsia on-and-off over the past ten years

Medicines
  • Cilazapril (5 mg once daily)
  • Omeprazole (20 mg, as required once daily)

Family history
  • No significant family history of cardiovascular disease

Social history
  • Works as an accountant and is sedentary for the majority of the day
  • He tries to go for a short walk every evening and plays the occasional round of golf
  • Has a glass of wine with dinner every night, followed by a “stiff” gin and tonic while he watches television; his consumption usually increases in the weekend
    • Ken was advised to reduce his drinking following the diagnosis of CKD and hypertension but reports he has not done so
  • Quit smoking one year ago (20 pack-years at the point of smoking cessation)

ACR, albumin:creatinine ratio; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate.

Relevant examination findings:

  • Heart rate: 123 bpm (apical rate) and 105 bpm (radial rate). Rhythm is irregularly irregular.
  • Blood pressure: 150/90 mmHg (confirmed by repeat measurement)
  • BMI: 30.24 (height: 187 cm; weight: 108 kg)
  • No signs of heart failure were found during the examination
  • An ECG confirms a diagnosis of atrial fibrillation with a rate of 125

Blood results:

  • Complete blood count: within normal limits
  • Serum electrolytes: within normal limits
  • Ken’s calculated creatinine clearance (CrCl) is 47 mL/min
  • HbA1c: within normal limits
  • Thyroid function: within normal limits
  • Liver function: within normal limits

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