What is the best management approach for an elderly male patient with a history of coronary artery disease (CAD) status post coronary artery bypass grafting (CABG), sick sinus syndrome (SSS) with a single-chamber pacemaker, persistent atrial fibrillation (A-fib) on Xarelto (rivaroxaban), hypertension (HTN), hyperlipidemia (HLD), type 2 diabetes mellitus (DM2), and chronic obstructive pulmonary disease (COPD), who presents with increased shortness of breath on minimal exertion?

Management of Elderly Male with CAD, SSS, Persistent A-fib, and Exertional Dyspnea

Your immediate priority is to obtain a transthoracic echocardiogram urgently to assess for heart failure with preserved ejection fraction (HFpEF), which occurs in up to 57% of first heart failure hospitalizations and is strongly associated with hypertension and atrial fibrillation in this exact patient population. 1, 2

Immediate Diagnostic Workup

Critical first step: Assess hemodynamic stability - Check for systolic BP <90 mmHg, altered mental status, pulmonary edema with respiratory distress, or ongoing myocardial ischemia, as these require immediate intervention. 2

Essential Diagnostic Tests

• Transthoracic echocardiography (TTE) - This has 80.6% sensitivity and specificity for diagnosing acute heart failure and must evaluate: 1, 2

  • Left ventricular ejection fraction and wall motion abnormalities
  • Left ventricular wall thickness (unexplained thickening may indicate cardiac amyloidosis, particularly in patients over 60 with heart failure symptoms and atrial fibrillation) 2
  • Diastolic function parameters including E/e' ratio and left atrial volume index 1
  • Right ventricular function (RV systolic dysfunction has prognostic significance in HFrEF patients) 1
  • Valvular function, particularly mitral regurgitation severity 1

• Assess pacemaker function - Verify appropriate pacing, rule out pacemaker-mediated tachycardia, and evaluate for chronotropic insufficiency (present in 20% of dyspneic patients and can cause exertional symptoms) 3

• Rhythm monitoring beyond 24 hours - Recommended for NSTEMI patients at increased risk for cardiac arrhythmias, which applies to this patient with recent syncope/bradycardia. 1

Functional Assessment

Classify dyspnea severity using NYHA classification: 1

• Your patient appears to be NYHA Class III (marked limitation; less than ordinary activity causes dyspnea, comfortable at rest)
• This classification directly impacts prognosis and treatment intensity

Evaluate for anginal symptoms using CCS classification to determine if ischemia contributes to dyspnea. 1

Rate Control Strategy

**Target resting heart rate <110 bpm initially** - Rate control takes priority over other interventions in patients with atrial fibrillation and heart rate >110 bpm. 2

• Beta-blockers are first-line given his CAD history, providing dual benefit for rate control and ischemic heart disease management 2, 4
• Digoxin may be added as adjunct therapy if heart failure is present 4
• Avoid non-dihydropyridine calcium channel blockers (diltiazem/verapamil) if significant heart failure is confirmed, as they can worsen systolic dysfunction

Blood Pressure Management

Target BP <130/80 mmHg using RAAS blockade (ACE inhibitors or ARBs), as these agents reduce atrial remodeling, decrease AF burden, and improve heart failure outcomes. 2

Anticoagulation Verification

Continue Xarelto (rivaroxaban) for stroke prevention - This patient has multiple risk factors for thromboembolism including age, diabetes, hypertension, and persistent atrial fibrillation. 4, 5, 6

• His CHA₂DS₂-VASc score warrants continued anticoagulation 2
• Rivaroxaban is appropriate for AF patients with CAD 7, 8, 6

Evaluation for Graft Patency

Consider stress testing or coronary angiography if echocardiography reveals new wall motion abnormalities or if anginal symptoms are present, as graft failure could explain exertional dyspnea in a post-CABG patient. 1

• Monitor for new-onset angina at rest or lasting >20 minutes (suggests unstable angina) 9
• Angina with less than ordinary activity (walking <2 blocks or climbing <1 flight of stairs) indicates CCS Class III and warrants urgent assessment 9

Critical Pitfalls to Avoid

Never assume rapid ventricular rate is the primary problem - Always search for secondary causes like pulmonary embolism, acute coronary syndrome, or sepsis in patients with multiple comorbidities. 2

Do not overlook cardiac amyloidosis - In patients over 60 with unexplained LV wall thickening, heart failure symptoms, atrial fibrillation, and low ECG voltage, this diagnosis must be considered. 2

Do not assume bronchospasm is primary in patients with COPD and multiple cardiac risk factors - Acute pulmonary edema from rapid atrial fibrillation can mimic COPD exacerbation. 2

Comorbidity Optimization

Optimize diabetes, hypertension, and hyperlipidemia management to reduce atrial arrhythmia progression and cardiovascular risk. 4

Ensure adequate COPD management but recognize that cardiac causes are more likely given his extensive cardiac history. 3

Warning Signs Requiring Urgent Re-evaluation

Monitor for: 9

• Worsening dyspnea at rest or with less activity (NYHA Class IV progression)
• Presyncope or syncope (suggests hemodynamic compromise from rapid ventricular response or ventricular arrhythmias)
• New chest pain, particularly if exertional or lasting >20 minutes
• Rapid weight gain >2-3 pounds in 1-2 days (fluid retention)
• Focal neurological symptoms (stroke risk with AF)

Follow-up Monitoring

Annual extended ambulatory monitoring is recommended for AF patients with heart failure to detect asymptomatic paroxysmal AF and assess arrhythmia burden. 9

Serial echocardiography every 1-2 years to assess cardiac function and structural changes. 4