What symptoms should be monitored in a patient with Ischemic Heart Disease (IHD) and Atrial Fibrillation (AF) with rapid ventricular response (RVR), a CHA2DS2-VASc score of 2, and classified as New York Heart Association (NYHA) Functional Class III?

Critical Symptoms to Monitor in IHD with AF-RVR, CHA₂DS₂-VASc 2, NYHA FC III

Monitor vigilantly for worsening dyspnea at rest or with minimal exertion, new or worsening chest pain (particularly at rest or with less than ordinary activity), palpitations, presyncope/syncope, and any neurological symptoms suggesting stroke, as this patient's combination of ischemic heart disease, rapid ventricular response, and NYHA Class III heart failure creates high risk for acute decompensation, myocardial ischemia, and thromboembolic events. 1, 2

Cardiac Ischemia Warning Signs

Angina Pattern Changes:

• New-onset angina at rest or lasting >20 minutes suggests unstable angina requiring immediate evaluation 1
• Angina occurring with less than ordinary activity (walking <2 blocks on level ground or climbing <1 flight of stairs) indicates progression to CCS Class III angina 1
• Acceleration of angina severity by at least one CCS class warrants urgent assessment 1
• Any chest pain, pressure, or discomfort in the chest, neck, or arms that is clearly exertional or consistent with myocardial ischemia 1

Heart Failure Decompensation Indicators

NYHA Class III patients are at marked limitation baseline and can rapidly deteriorate:

• Worsening dyspnea with less than ordinary activity or new dyspnea at rest signals acute decompensation 1
• Increased fatigue or inability to perform any physical activity without discomfort suggests progression to NYHA Class IV 1
• New or worsening peripheral edema, orthopnea, or paroxysmal nocturnal dyspnea indicates fluid overload 1
• Rapid weight gain (>2-3 pounds in 1-2 days) from fluid retention 1

Arrhythmia-Related Symptoms

Rapid ventricular response creates specific risks:

• Palpitations with associated chest pain or dyspnea may indicate inadequate rate control contributing to ischemia 2
• Presyncope or syncope suggests hemodynamic compromise from RVR or ventricular arrhythmias 1
• Irregular pulse with varying intensity of heart sounds on physical examination 3
• New irregular jugular venous pulsations may indicate worsening AF burden 3

Thromboembolic Event Warning Signs

With CHA₂DS₂-VASc score of 2, this patient requires anticoagulation and stroke surveillance:

• Any focal neurological symptoms including weakness, numbness, speech difficulty, vision changes, or facial droop require immediate stroke evaluation 1, 4
• Sudden severe headache may indicate hemorrhagic stroke, particularly if on anticoagulation 1
• Transient ischemic attack symptoms (resolving neurological deficits) still mandate urgent evaluation 1
• Symptoms of systemic embolism including acute limb ischemia (pain, pallor, pulselessness) 4

Ventricular Arrhythmia Surveillance

IHD patients with heart failure are at high risk:

• Sustained palpitations, particularly if associated with lightheadedness or chest pain, may represent ventricular tachycardia 1
• Recurrent presyncope or syncope warrants evaluation for life-threatening ventricular arrhythmias 1
• Ambulatory ECG monitoring should detect premature ventricular complexes and episodes of non-sustained ventricular tachycardia, which are common in this population 1

Medication-Related Complications

Rate control and anticoagulation create specific monitoring needs:

• Excessive bradycardia symptoms (severe fatigue, dizziness, syncope) from overly aggressive rate control 2
• Signs of bleeding (melena, hematuria, easy bruising, prolonged bleeding) if anticoagulated 1, 4, 5
• Worsening heart failure symptoms after initiation of beta-blockers or calcium channel blockers 2

Monitoring Frequency and Approach

Extended ambulatory monitoring is recommended:

• Annual extended ambulatory monitoring (beyond standard 24-48 hours) is recommended for AF patients with heart failure to detect asymptomatic paroxysmal AF and assess arrhythmia burden 1
• Serial monitoring every 1-2 years for ventricular arrhythmias in patients without ICDs 1
• Immediate extended monitoring if new symptoms develop to correlate symptoms with rhythm 1, 3

Critical Pitfalls to Avoid

• Do not dismiss "atypical" chest pain in this population—pain, pressure, or discomfort in the chest, neck, or arms not clearly exertional may still represent myocardial ischemia 1
• Do not attribute all dyspnea to heart failure—consider acute coronary syndrome, pulmonary embolism, or pneumonia as alternative diagnoses 2
• Do not delay stroke evaluation for any neurological symptoms, even if transient—time is critical for intervention 1, 4
• Ensure adequate anticoagulation with CHA₂DS₂-VASc score of 2, as this mandates oral anticoagulation to prevent stroke 1, 4