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The patient has a low ejection fraction with systolic heart failure, probably secondary to hypertension. His heart fail-ure must be treated first, followed by careful control of the hypertension. He was initially treated with a diuretic (furo-semide, 40 mg twice daily). On this therapy, he was less short of breath on exertion and could also lie flat without dyspnea. An angiotensin-converting enzyme (ACE) inhib-itor was added (enalapril, 20 mg twice daily), and over the next few weeks, he continued to feel better. Because of continued shortness of breath on exercise, digoxin at 0.25 mg/d was added with a further modest improvement in exercise tolerance. The blood pressure stabilized at 150/90 mm Hg, and the patient will be educated regarding the relation between his hypertension and heart failure and the need for better blood pressure control. Cautious addition of a β blocker (metoprolol) will be considered. Blood lipids, which are currently in the normal range, will be monitored.
Robert D. Harvey, PhD, & Augustus O. Grant, MD, PhD*
A 69-year-old retired teacher presents with a 1-month history of palpitations, intermittent shortness of breath, and fatigue. She has a history of hypertension. An electrocardiogram (ECG) shows atrial fibrillation with a ventricular response of 122 beats/min (bpm) and signs of left ventricular hypertrophy. She is anticoagulated with warfarin and started on sustained-release metoprolol, 50 mg/d. After 7 days, her rhythm reverts to normal sinus rhythm spontaneously. However, over the ensuing month, she continues to have intermittent palpita-tions and fatigue. Continuous ECG recording over a 48-hour period documents paroxysms of atrial fibrillation with heart rates of 88–114 bpm. An echocardiogram shows a left ven-tricular ejection fraction of 38% (normal ≥ 60%) with no localized wall motion abnormality. At this stage, would you initiate treatment with an antiarrhythmic drug to maintain normal sinus rhythm, and if so, what drug would you choose?