A 63-year-old man with coronary artery disease (CAD) and New York Heart Association Class I heart failure presents for a routine semi-annual clinic visit. He was first diagnosed with CAD nine years ago, when he presented with exertional chest pain. Following an abnormal stress test, cardiac catheterization revealed moderate right CAD and severe left anterior descending artery disease. His left ventricular ejection fraction (LVEF) was 59%. Two stents were placed in the left anterior descending artery (LAD) and he was started on a ß-blocker, aspirin, clopidogrel, and a statin.
He remained stable for six years, but then his exertional angina returned. Repeat catheterization showed progressive disease in the right coronary artery (RCA) with new disease in an obtuse marginal (OM) branch of the circumflex artery. His LVEF had also diminished to 38%. Stents were placed in the RCA and OM arteries, and his ß-blocker dose was increased.
Today, he reports that over the past six months, his heart rate has been slow and often skips beats. He stopped taking his ß-blocker, hoping it would help speed up his heart; it didn’t. He says he feels fine right now (although his heart continues to skip beats). He says he can climb a flight of stairs without difficulty and denies chest pain, dyspnea, dizziness, or syncope. At night, he sleeps on one or two pillows. He denies orthopnea, paroxysmal nocturnal dyspnea, or peripheral edema.
Medical history includes type 2 diabetes (controlled with diet and exercise), degenerative joint disease, and hyperlipidemia. Surgical history includes a tonsillectomy and trigger finger repair of the left third digit. His current medications include clopidogrel, losartan, pravastatin, spironolactone, and aspirin. He has no known drug allergies.
The patient used to be a heavy smoker (> 2 packs/d) but quit after his first stent was placed. He drinks one to two glasses of wine per week and denies recreational drug use.
Family history is positive for coronary artery disease and stroke. His father died of CAD at age 60, and his mother of heart failure at 58.
A review of systems is noncontributory. Vital signs include a blood pressure of 118/80 mm Hg; pulse, 53 beats/min; temperature, 37°C; respiratory rate, 14 breaths/min-1; and O2 saturation, 96% on room air. His weight is 214 lb and his height, 70 in.
Physical exam reveals an alert, well-kept male in no distress. Pertinent findings include a regularly irregular pulse and normal S1 and S2, with no murmurs, gallops, or rubs. The lungs are clear bilaterally. The abdomen is soft and benign with no organomegaly. Peripheral pulses are 2+ bilaterally, and there is no peripheral edema or calf tenderness. Neurologic exam shows a grossly intact sensory and motor system with no focal signs.
An ECG reveals a ventricular rate of 55 beats/min; PR interval, 146 ms; QRS duration, 122 ms; QT/QTc interval, 424/405 ms; P axis, 60°; R axis, 38°; and T axis, 29°. What is your interpretation?
