CASE PRESENTATIONCASE PRESENTATION

Patient MC, male, 87ani, rural

Presenting Complaint:

• Atypical thoracic pain

• Vertigo

• Dyspnea at rest / Paroxysmal nocturnal dyspnea

• Cephalalgia

• disorientation

• Anxiety

• Emotional lability

Family Medical History- can not specify

Past Medical History 2001 - head trauma 2010 - Benign prostatic hyperplasia (long term

urinary catheterization) -Chronic Urinary Retention -chronic kidney disease -urinary tract infection -permanent atrial fibrillation -ischemic heart disease

Social historySocial historyretiree (former farmer)Lives alone

Former smokerNo alcohol consumption – in present

TreatmentDigoxin 0,25mg/day (declarative) Furosemide/Spironolactone 20/50mg -

intermittentCarvedilole ?

History of the present illnessHistory of the present illness

Patient was admitted for atypical thoracic pain, dyspnea at rest and important neurological symptoms: cephalalgia, disorientation, anxiety, vertigo, emotional lability. Symptoms occurred progressively for approximately a month.

Non-adherent to chronic treatment.

Does not now the drugs, doses or timing

Clinical examenClinical examen

Influenced general condition

Periods - fully oriented for person, place and time alternate with periods of temporospatial disorientation

BMI = 20 kg/m2 Skin- dehydrated, dry, persistent skinfold Osteoarticular pain Bradycardia with irregular rate and rhythm, HR=50

bpm, no murmurs, rubs or gallops BP supine = 110/50 mmHg BP orthostatism = 95/50 mmHg Mild abdominal pain centered in hypogastrium Urinary catheter present, permeable

PERMANENT ATRIAL FIBRILLATION WITH SLOW PERMANENT ATRIAL FIBRILLATION WITH SLOW VENTRICULAR RESPONSE VENTRICULAR RESPONSE

DIGOXIN TOXICITYDIGOXIN TOXICITY

HEART FAILUREHEART FAILURE

DELIRIUMDELIRIUM

ISCHAEMIC HEART DISEASEISCHAEMIC HEART DISEASE

BENIGN PROSTATIC HYPERPLASIABENIGN PROSTATIC HYPERPLASIA

URINARY TRACT INFECTIONURINARY TRACT INFECTION

Diagnostic Supposition:Diagnostic Supposition:

SIMPTOMATIC BRADICARDIASIMPTOMATIC BRADICARDIA

NEUROPSYCHIATRIC SYMPTOMS (DELIRIUM):NEUROPSYCHIATRIC SYMPTOMS (DELIRIUM):

##Neurologic disordersNeurologic disorders: dementia: dementia

brain CT – cerebral atrophy and lacunae brain CT – cerebral atrophy and lacunae

# # Non-neurologic organic disordersNon-neurologic organic disorders: Due to : Due to bradycardia → low cardiac output → insufficient cerebral bradycardia → low cardiac output → insufficient cerebral perfusionperfusion

DIAGNOSTIC CHALLENGESDIAGNOSTIC CHALLENGES

Bradycardia - causes

Drug toxicity- Carvedilol and digoxin treatment at home with

nonadherence to treatment- labs: digoxinemia

sinus node dysfunction.-frequent in elderly-associated with ischemic heart disease-exploratory: EKG Holter and ecocardiography

hypothyroidism -with bradipsyhia, - labs: TSH

Labs – Blood TestsLabs – Blood Tests

Digoxinemia 2,9 ng/ml

TSH=2,4 microU/l

ESR=10mm/h RBC=4,01 mil/mmc HB=12,4 g/dl HT=36,4 %

CK-MB=19,3 u/l

UREEA=74 mg/dl CREATININE=1, 16 mg/dl Clcr=50 ml/min

K=4,6 mmol/l NA=138 mmol/l

Glycemia = 83mg/dlGlycemia = 83mg/dl

TP = 62g/lTP = 62g/l

GOT=16U/L GPT=12U/L GGT=35U/LGOT=16U/L GPT=12U/L GGT=35U/L

Cholesterol = 145mg/l Triglycerides = 83mg/lCholesterol = 145mg/l Triglycerides = 83mg/l

UrinalysisUrinalysis = frequent leucocytes, relative frequent red = frequent leucocytes, relative frequent red blood cells, microbial florablood cells, microbial flora

Urine culture - positive = KlebsiellaUrine culture - positive = Klebsiella

Labs – Blood Tests (2)Labs – Blood Tests (2)

Exploratory (3)

Chest X-ray : prolonged inferior heart arch

ECHOCARDIOGRAFIA - LV 53/37 IVS=LVPW= 9, EF=30%, LA=37/45, RA=40/46, RV=28 , diffuse hypokinezia, MI grII, mitral valves and ring with calcifications , AoI grI, aortic valves with calcifications, TI grII. No pericardial effusion, no intracavitar thrombi.

EKG -

GERIATRIC EVALUATION SCALES

MMSE = 12

MNA = 17

GDS = 12

HATCHINSKI SCORE = 6

Diagnostic :Diagnostic :

Permanent Atrial Fibrillation with Low Ventricular response

Digoxin Toxicity Ventricular Extrasitoly Ischemic Heart Disease Mild Cognitive Impairment Benign Prostatic Hyperplasia Urinary tract Infection with Klebsiella Normochromic Normocytic Anemia

Treatment

STOP drugs with bradycardic effect

Oxygen (facial mask) 2l/min, intermittent

Hydration oral + iv

Aspenter 75 mg/day

Isosorbid dinitrat 20 mg x 2/day

Amoxicillinum+clavulanate 1,2g q12h (as result of antibiograme))

Evolution

Persistence of bradycardia on 10th day after medication (with bradycardia effect) stop

+ One episode with tachycardia (140 bpm) with

delirium symptoms+ Repeated normal seric Digoxinemia (0,2 ng/l) –

excludes a digoxin toxicity= High suspicion of Sick Sinus Sindrome HOLTER EKG

HOLTER EKG- Atrial fibrillation with low ventricular rhythm media: 37-44bpm, minim of 27bpm, 6400 pauses larger than 2,5 sec, 2 episodes of ventricular tachycardia

Final DIagnostic:Final DIagnostic:

Permanent Atrial Fibrillation with Low Ventricular response

Ventricular Tachycardia Sick Sinus Syndrome Ischemic Heart Disease Mild Cognitive Impairment Benign Prostatic Hyperplasia Urinary tract Infection with Klebsiella Normochromic Normocytic Anemia

xilinaxilina 1 microg/min (6mil/h) civp on 1 microg/min (6mil/h) civp on injectomatinjectomat

Due to bradycardia – no oral treatmentDue to bradycardia – no oral treatment

permanent pacemaker- permanent pacemaker- transferred to transferred to IBCV IasiIBCV Iasi

TreatmentTreatment

Short term evolutionShort term evolution

Favorable post-CEP: all cardiac symptoms disappeared; HR was

constant 70 bpmNeurological symptoms (vertigo, cephalalgia)

disappeared with no more delirium episodes.

Improvement of psychological and emotional status. No more disorientation episodes, improved cooperation, improved quality of live improvement of MMSE (MMSE=16 from 12-at admission)

Influenced byInfluenced by

* * numerous comorbiditynumerous comorbidity

* * presence of cognitive disorderpresence of cognitive disorder

* * Insufficient familial supportInsufficient familial support

* * High risk for iatrogenyHigh risk for iatrogeny

Long term evolutionLong term evolution

Discussions

In elderly patient the symptoms are frequent nonspecific → delayed diagnose

Polimedication and social environment are causes of drug toxicity, thus high iatrogenic risk

Because of cognitive impairment and constant need for care its necessary a greater familial support, social support or institutionalization

Neurological symptoms Neurological symptoms in elderly – are due to in elderly – are due to another conditions not only dementiaanother conditions not only dementia

the psychic disorder the psychic disorder was triggered by the low was triggered by the low cardiac output secondary the malign cardiac cardiac output secondary the malign cardiac rhythm disorderrhythm disorder

Discussions 2Discussions 2

Sick Sinus Syndrome Sick Sinus Syndrome is a frequent condition in is a frequent condition in elderly. It is caused (mostly) by the ischemic elderly. It is caused (mostly) by the ischemic heart diseaseheart disease

Permanent pacemaker implantation Permanent pacemaker implantation has no has no age limitation and has fewer side effects than age limitation and has fewer side effects than medicationmedication

Discussions 3Discussions 3