What is the diagnosis and management for a 71-year-old female with a history of dizziness and loss of memory, now resolved, presenting with atrial fibrillation, cardiomegaly, congestive changes on chest PA, impaired renal function, and hepatic dysfunction, with vital signs showing bradycardia and blood pressure of 140/80 mmHg?

Diagnosis: Acute Decompensated Heart Failure with Atrial Fibrillation and Slow Ventricular Response

This 71-year-old female has acute decompensated heart failure (ADHF) precipitated by atrial fibrillation with slow ventricular response, complicated by renal and hepatic dysfunction, requiring immediate diuresis, rate control optimization, anticoagulation assessment, and investigation of the underlying bradycardia mechanism. 1

Primary Diagnosis and Contributing Factors

Acute Decompensated Heart Failure:

• Bibasal rales on examination indicate pulmonary congestion 1
• Cardiomegaly with congestive changes on chest X-ray confirms volume overload 1
• Elevated BUN (7.97 mmol/L, approximately 22 mg/dL) with creatinine 94.2 μmol/L (approximately 1.07 mg/dL) suggests prerenal azotemia from poor cardiac output 2, 3

Atrial Fibrillation with Slow Ventricular Response:

• ECG shows AF with slow ventricular response plus PVCs 1
• Bradycardia in AF may represent sick sinus syndrome (tachycardia-bradycardia syndrome), excessive AV nodal blockade from medications, or intrinsic AV nodal disease 4
• The combination of AF and bradycardia increases risk of bradycardia-induced ventricular arrhythmias 4

Hepatic Dysfunction:

• SGPT 62.48 U/L and SGOT 86.27 U/L suggest hepatic congestion from right heart failure or cardiogenic cirrhosis 1
• Elevated uric acid (479.39 μmol/L, approximately 8 mg/dL) may reflect reduced renal clearance and tissue hypoperfusion 2

Transient Neurological Symptoms (Resolved):

• Dizziness and memory loss likely represented cerebral hypoperfusion from bradycardia and low cardiac output 4, 5
• Now resolved with intact sensorium, but warrants stroke risk assessment 1

Immediate Management Algorithm

Step 1: Stabilize Hemodynamics and Treat Heart Failure

Diuresis:

• Initiate IV furosemide 20-40 mg bolus, then continuous infusion or intermittent dosing based on urine output and clinical response 1
• Monitor strict intake/output, daily weights, and electrolytes (particularly potassium and magnesium) 6
• Target net negative fluid balance of 1-2 liters daily until euvolemia achieved 1

Blood Pressure Management:

• Current BP 140/80 mmHg is acceptable; avoid aggressive reduction that could worsen renal perfusion 1
• If hypertension persists after decongestion, consider ACE inhibitor or ARB (dose-adjusted for renal function) 1

Step 2: Address Bradycardia and Rate Control

Investigate Cause of Bradycardia:

• Review all medications for AV nodal blocking agents (beta-blockers, calcium channel blockers, digoxin, amiodarone) that may be causing excessive bradycardia 1
• Check digoxin level if patient is on digoxin, as renal dysfunction increases toxicity risk 1
• Obtain 24-hour Holter monitor to assess for sinus node dysfunction, AV block, and bradycardia-tachycardia syndrome 1, 4

Management of Slow Ventricular Response:

• If bradycardia is medication-induced: Reduce or discontinue offending agents 1
• If intrinsic conduction disease: Consider temporary pacing if symptomatic bradycardia recurs or if heart rate consistently <40 bpm 4
• Target heart rate: 60-80 bpm at rest once acute decompensation resolves 1

Critical Pitfall: Do not aggressively treat rate control in AF with already slow ventricular response; this may precipitate complete heart block or asystole 4

Step 3: Anticoagulation for Stroke Prevention

Assess Stroke Risk (CHA₂DS₂-VASc Score):

• Age ≥75 years = 2 points
• Hypertension (BP 140/80) = 1 point
• Heart failure = 1 point
• Female sex = 1 point
• Total = 5 points = HIGH stroke risk (4.31% annual risk) 1

Assess Bleeding Risk:

• Renal dysfunction (creatinine 94.2 μmol/L) increases bleeding risk 1, 2, 3
• Hepatic dysfunction (elevated transaminases) increases bleeding risk 1
• Elderly age increases bleeding risk 1

Anticoagulation Recommendation:

• Initiate oral anticoagulation despite bleeding risks, as stroke risk substantially outweighs bleeding risk at CHA₂DS₂-VASc ≥5 1
• Preferred agent: Apixaban 5 mg twice daily (or 2.5 mg twice daily if ≥2 of: age ≥80, weight ≤60 kg, creatinine ≥133 μmol/L) 1
• Alternative: Warfarin with target INR 2.0-2.5 (lower range preferred given bleeding risk factors) 1
• Avoid: Dabigatran (requires CrCl >30 mL/min and has higher bleeding risk in elderly) 1
• Monitor renal function every 3-6 months as declining function may require dose adjustment 1, 2, 3

Step 4: Rhythm Management Decision

Do NOT pursue cardioversion or rhythm control at this time:

• Patient is hemodynamically stable with resolved symptoms 1
• Bradycardia contraindicates most antiarrhythmic drugs (amiodarone, sotalol, flecainide, propafenone all cause bradycardia) 1
• Structural heart disease (cardiomegaly, heart failure) increases proarrhythmic risk of Class IC agents 1
• Renal and hepatic dysfunction limit safe use of antiarrhythmics 1

Rate control strategy is preferred:

• Accept permanent AF with rate control once acute decompensation resolves 1
• If rate control medications are needed after bradycardia resolves, use low-dose beta-blocker (metoprolol 12.5-25 mg twice daily) or digoxin 0.0625-0.125 mg daily (adjusted for renal function) 1

Step 5: Additional Diagnostic Workup

Echocardiography (urgent):

• Assess left ventricular ejection fraction, chamber sizes, valvular function, and wall motion abnormalities 1
• Evaluate for left atrial thrombus (though TEE more sensitive if cardioversion considered) 1

Laboratory Monitoring:

• Daily: Electrolytes (K⁺, Mg²⁺), creatinine, BUN 6
• Baseline: TSH (exclude thyrotoxicosis as AF trigger), troponin (exclude acute coronary syndrome), BNP/NT-proBNP (baseline for future comparison) 1, 7
• Recheck liver function tests in 1 week to assess for improvement with decongestion 1

Exclude Reversible Causes:

• Thyrotoxicosis (check TSH) 1, 7
• Acute coronary syndrome (check troponin, though SGOT elevation may be cardiac) 7
• Pulmonary embolism (low suspicion given no dyspnea, but consider if clinical deterioration) 7
• Infection (no fever, but elderly may have blunted response) 8

Disposition and Follow-Up

Admit to telemetry unit:

• Continuous cardiac monitoring for bradycardia, pauses, and ventricular arrhythmias 4
• Monitor response to diuresis and watch for worsening renal function 2, 3

Cardiology consultation:

• Evaluate need for permanent pacemaker if intrinsic conduction disease confirmed 4
• Consider electrophysiology referral if bradycardia-tachycardia syndrome confirmed and pacemaker indicated 4

Discharge criteria:

• Euvolemia achieved (clear lungs, no peripheral edema) 1
• Stable renal function 2, 3
• Heart rate 60-100 bpm without symptomatic bradycardia 1
• Therapeutic anticoagulation established 1

Outpatient follow-up:

• Cardiology within 1-2 weeks 1
• Recheck electrolytes, renal function, and liver function in 1 week 6, 2
• Monitor INR weekly if on warfarin until stable, then monthly 1
• Renal function monitoring every 3-6 months if on DOAC 1, 2, 3

Critical Pitfalls to Avoid

• Never attribute bradycardia solely to AF without investigating for medication effects, sinus node dysfunction, or AV block 4
• Never withhold anticoagulation in high-risk AF patients (CHA₂DS₂-VASc ≥5) based solely on bleeding risk concerns 1
• Never use Class IC antiarrhythmics (flecainide, propafenone) in patients with structural heart disease or heart failure 1
• Never use sotalol or dofetilide in patients with renal dysfunction without dose adjustment and in-hospital QT monitoring 1
• Never aggressively diurese without monitoring renal function, as cardiorenal syndrome may develop 2, 3
• Never assume resolved neurological symptoms exclude stroke; maintain high suspicion and anticoagulate appropriately 1, 5