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Patient A. S.

A. S. is a 66-year-oid woman who has had insulin-dependent diabetes mellitus for many years. She has had cholecystectomy, hysterectomy, cataract removal (bilateral) and right ankle pinning. Her blood pressure has been elevated in the past. The patient has been hospitalized 4 times in the past 9 months for congestive heart failure. There has been a concomitant history of lightheadedness and a "fluttering sensation" in the chest. She has had chest discomfort but denies dyspnea. Prior hospitalizations have documented occasional sinus bradycardia (35-40 bpm), atriai fibrillation (one brief episode), left bundle branch block, rare sinus pauses (up to 1.8 seconds) and some multifocal ventricular extrasystoles. Assessment shows concentric left ventricular hypertrophy (echocardiogram) decrease in ejection fraction with exercise (55% to 37%) and restoration with nitroglycerine (37% to 53%). Ventriculography documents a slightly decreased ejection fraction (53%) and generalized minimal hypokinesis. Angiography demonstrates insignificant coronary artery plaquing. A limited eiectrophysiologic study shows no atrial dysrhythmia with extrastimulation and absent ventriculoatrial (VA) conduction. See Figures 7 and 8.