A Case Study of One Woman’s Experience with Atrial Fibrillation
Patsy is a 64-year-old, otherwise healthy, Caucasian female with zero cardiac risk factors, save for about 15 excess pounds of body habitus. Throughout the course of the past 25 years, she had experienced sporadic events which included heart palpitations, flutters, and intense heart racing. She always correlated these events to anxiety attacks and related symptoms of the same – atrial fibrillation was the furthest item from her mind. She was continually subjected to a quite demanding schedule, with a full-time executive position in the sales department of a major corporation as well as a busy family life with two children and a household to maintain. As time went on, her children grew up and moved out, and she retired from her position.
However, she was still the first person to be contacted when it came to supervising grandchildren and was also expected to complete most of the daily upkeep tasks in the home she shares with her fiance. To compound this, her oldest son was incarcerated in state prison for a period of three years, and her life became consumed with this situation, leaving her in a constant state of anxiety and mental anguish. As such, with these events being attributed to anxiety, Patsy never sought medical treatment for them; and even when she went to her primary provider for health maintenance visits, her vital signs were always within normal range, and all of her preventive screening tests were always normal. With the belief her condition was a complication of anxiety, Patsy was determined not to take a sedative-hypnotic drug such as Valium or Xanax to combat these suspected panic attacks, and as such, attempted to always practice psychological methods such as deep breathing and meditation to alleviate these spells. With this train of thought, the focus on any sort of follow-up treatment for these anxiety attacks faded from her mental process. However, she would soon learn things were not as they appeared.
Abruptly, on September 3, 2015, Patsy was awakened at approximately 4:30 a.m. with an inability to swallow or form words. Her son, who had been released from prison, noticed the dysarthria and a bit of a facial droop and took her to the local hospital. The symptoms were pronounced to Patsy, but subtle to observing hospital staff and treating physicians, and as such, they did not think there was a serious neurologic etiology to them. During routine testing, a heart rate of 145 beats per minute was observed along with an irregular rhythm, and atrial fibrillation was felt to be the culprit and was diagnosed as such. At this point, Patsy’s youngest son was contacted and notified of these events. Having a medical background, he promptly suggested to the admitting physician it was simply an impossibility to have neurologic symptoms such as dysphagia and dysarthria with atrial fibrillation unless a thromboembolic stroke had occurred as a result of a traveling blood clot. The treating team ignored this, and consequently, did not perform a CT scan or MRI of the brain upon presentation to the emergency room. Therefore, new, potentially life-saving treatments, such at the administration of TPA and other articles of stroke protocol, were not considered.
During the first day of hospitalization, Patsy’s youngest son visited her in the hospital, at which time the right-sided weakness and dysarthria became worse. Critical care staff members were consulted, yet they still felt this was not stroke-related, for some reason unknown. She continued through the night with these symptoms worsening. Then, upon morning rounds, the hospitalist physician took one look at his patient and immediately ordered an MRI of the brain, which confirmed the presence of four old, small-vessel, lacunar-type infarctions, with one acute — or new — stroke happening that morning. Patsy was immediately transferred to a certified stroke center’s intensive care unit, where she was sufficiently anticoagulated and released within 8 days with the residual effects greatly diminished.
Moving along, about a month after the hospital admission and diagnosis, Patsy returned to the cardiology department for a routine follow-up appointment. At this visit, her heart rate was 84 and regular. Just as the cardiologist was leaving the room to otherwise give her a clean bill of health with instructions to return in one year, he decided to repeat her manual cardiac examination and found she had spontaneously converted to atrial fibrillation. She was then sent for an EKG and admitted back to the hospital, with the physician concerned for a new-onset, and extremely lethal form of ventricular tachycardia occurring concurrently with the atrial fibrillation. Needless to say, her level of care was upgraded to include 24-hour close observation in the Cardiac Critical Care Unit of the University of Florida Hospital. Fortunately, the ventricular origin of the arrhythmias was eventually ruled out after cardiac catheterization and CT angiography. However, upon identification of the cells responsible for the atrial fibrillation, it was determined the risk of further complication was too great to proceed with a curative procedure such as ablation, yet implantation of an AICD was not something Patsy was ready to consider unless there was no hope of medical management. Today, she is sufficiently managed with a new-generation anticoagulant called Eliquis as well as heart rate/rhythm controlled with metoprolol and Cardizem. She also received statin therapy as a secondary prevention method to prevent harmful low-density lipoprotein, the so-called “bad cholesterol,” accumulation which can contribute to vessel stenosis.
Bearing this in mind, it is clear there were so many factors which contributed to Patsy’s situation. First of all, the stress in her personal life masked the symptoms of atrial fibrillation, including the palpitations she, otherwise, would have discussed with her primary physician. Secondly, because her atrial fibrillation is paroxysmal and intermittent, it was up to chance the irregular rhythm would be detected at a routine visit, and chance ruled against such detection. Additionally, during the beginning stages of hospitalization with the stroke symptoms, the treating physicians failed to treat the patient according to stroke protocol, and as such, her atrial fibrillation caused her to “throw” another clot that evening. Had she been evaluated for and deemed to be a candidate for TPA administration, there is a high probability the final lacunar infarction would have been prevented. In spite of these systemic failures, Patsy has made a 95% recovery in less than 6 months. However, the risk of a future stroke is now increased astronomically, and she will be on lifelong medication unless said medication eventually fails to suppress the arrhythmia, at which time she will require implantation of an AICD device in order to maintain normal sinus rhythm.
Unfortunately, many patients are not so fortunate. Many times, due to the unique challenges of identifying this intermittent form of atrial fibrillation and consequent challenges of treatment of the same, these patients may suffer from a larger vessel stroke, perhaps of the middle cerebral artery (MCA), which causes profound, permanent, debilitating residual neurologic symptoms and even death. In cases such as these, however, the patient will present to the hospital with such profound symptoms treating staff immediately begin stroke protocol and evaluation for clinical indication of TPA administration, which can greatly reduce the likelihood of stroke evolution, and in turn, can increase the patient’s chance of survival and recovery.
In summary, the lessons from Patsy’s story are profound, to say the least. In this presentation, all of the challenges associated with a proper diagnosis of atrial fibrillation were present. Because Patsy had no cardiac symptoms or risk factors of any kind and because of the stress level in her personal life, atrial fibrillation went undiagnosed, therefore leading to a series of strokes and further cardiac events. Had this been identified, proper medical management had a very real probability of preventing these strokes. This story illustrates the unique challenges atrial fibrillation creates, as well as the complications which can occur when the proper diagnosis does not happen. Therefore, it is important every member of a patient’s treatment team remain watchful for differential possibilities when a patient presents with symptoms such as palpitations with no other symptomatology, so as not to discount such symptoms as “anxiety.” Furthermore, it is equally important for the general population to be educated in the warning signs of major cardiac irregularities, such as atrial fibrillation and other ventricular events. Sadly, this is a case in which education and information could have prevented a number of complications from the condition, and it is ever-so-important misinformation and miscommunication such as this are precluded.