Cardiology Outpatient Letter

It was a pleasure to meet Mr. John Smith in outpatients clinic today. **Current Presentation** Mr. Smith presented with a primary complaint of increasing exertional dyspnoea and occasional palpitations over the last three months. He describes the dyspnoea as progressively worsening, now limiting him to walking short distances on level ground before becoming short of breath. The palpitations are irregular and typically last for a few seconds, accompanied by a sensation of fluttering in his chest. He denies any chest pain, syncope, or oedema. He is currently taking 10mg of atorvastatin daily for hypercholesterolaemia, which he reports has not changed in efficacy or side effects. Mr. Smith reports a sedentary lifestyle and a diet high in processed foods. **Background** 1. Mr. Smith has a history of essential hypertension, diagnosed five years ago, currently managed with ramipril. He reports good adherence to his medication regime, and his blood pressure has been well-controlled according to his general practitioner records. 2. He was diagnosed with hypercholesterolaemia two years ago, for which he takes atorvastatin. His most recent lipid profile, three months ago, showed LDL-cholesterol within target range. 3. He also has a history of type 2 diabetes mellitus, diagnosed seven years ago, currently managed with metformin. His HbA1c was 7.2% at his last check-up. **Family History** Mr. Smith's father passed away at the age of 62 due to a myocardial infarction. His mother has a history of atrial fibrillation and high blood pressure, for which she is on regular medication. There is no known family history of sudden cardiac death or congenital heart defects. His elder brother has type 2 diabetes, similar to Mr. Smith. **Drug History** Ramipril 5mg once daily Atorvastatin 10mg once daily Metformin 500mg twice daily Allergies: No known drug allergies. **Psychosocial History** Mr. Smith is a 58-year-old retired civil engineer. He lives with his wife in a semi-detached house. He reports occasional alcohol consumption, approximately two units per week. He quit smoking 10 years ago, having previously smoked 20 cigarettes per day for 30 years (30 pack years). He denies the use of any recreational drugs. He states that he enjoys gardening but finds himself increasingly limited by his breathlessness. **Clinical Examination** On clinical examination, Mr. Smith's blood pressure was 140/85 millimetres of mercury. His heart rate was 88 beats per minute and irregularly irregular. Heart sounds were S1 and S2, with an audible S4 gallop. Lung fields were clear to auscultation bilaterally, with no adventitious sounds. There was no presence of pedal oedema. **Electrocardiogram** The electrocardiogram showed an irregularly irregular rhythm, consistent with atrial fibrillation. The cardiac axis was normal. Electrical parameters revealed no evidence of pre-excitation or pathological T-wave inversion. There was evidence of left ventricular hypertrophy based on voltage criteria. **Echocardiogram** The echocardiogram demonstrated mild left ventricular hypertrophy with preserved biventricular systolic function. There was mild mitral regurgitation and mild tricuspid regurgitation. There was no evidence of significant valvular disease or pulmonary hypertension. The left atrial size was mildly dilated. **Impression** Mr. Smith presents with new-onset exertional dyspnoea and palpitations, with clinical and electrocardiographic evidence of atrial fibrillation. Given his multiple cardiovascular risk factors, including hypertension, hypercholesterolaemia, and diabetes, the current presentation suggests a possible cardiac origin for his symptoms. The echocardiogram findings of left ventricular hypertrophy and mild left atrial dilation are consistent with long-standing hypertension and the likely substrate for his atrial fibrillation. **Management Plan** 1. Initiate anticoagulation with apixaban 5mg twice daily. 2. Start bisoprolol 2.5mg once daily for rate control. 3. Refer for cardiology follow-up in four weeks. 4. Advise on lifestyle modifications including regular exercise and dietary changes. **Summary for Patient** We met today to discuss your breathlessness and heart fluttering. Your heart's rhythm is currently irregular, which is called atrial fibrillation, and we also noted that your heart muscle is slightly thickened. We are starting you on some new medications to help control your heart rhythm and to thin your blood, which is important to prevent problems. We will also arrange for you to see us again in about a month to check on your progress and make any necessary adjustments to your treatment.