[CRT-FORUM] 55S Preexcitation and dilated cardiomyopathy in elderly woman. Dr. Morales Salinas

[CRT-INFO]

Dear colleagues of the CRT symposium,
The debates are very interesting. Congratulations to the organizers of the
forum. I would like to share with you the following case:
Fifteen days ago, I received a woman in my office, with 60 something years,
with history of apparent health until around three months ago, when she
starts to experience maintained palpitations and besides "languidness" with
light strain. In the physical examination: gallop rhythm, non-crepitant, HR:
110x minute, BP: 120/80 mmHg and in the ECG, ventricular preexcitation
(possibly with right-anterior location). Functional class 3 of NYHA.
When questioned, she denied having personal history of angor, or sudden
dyspnea related to possible ischemic heart diseases; neither onset
palpitations crises nor sudden onset, or different from the current clinical
symptoms which would make us think of PSVT by accessory pathway. In
transthoracic Echo, LV in diastole 68 mm, moderate mitral valve
insufficiency, EF <35%.
I think that we cannot rule ischemia yet, or tachycardiomyopathy secondary
to orthodromic tachycardia as causes for the clinical symptoms.
Regardless of the cause, the hemodynamics of the patient would benefit much
from the pharmacological control of the HR: but digoxin, amiodarone,
anticalcium agents (verapamil) and beta blockers are contraindicated if
there is suspicion of tachycardia by this pathway.
According to some authors, beta blockers besides decreasing the conduction
velocity of the AV node, may also decrease the velocity of this pathway, so
maybe they are the lesser evil in terms of drug options. There are also
studies that support this, that show the benefits from beta blocking on HF
survival with severely depressed EF. On the other hand, IC drugs, due to a
poor ventricular function, are also dismissed. The patient is now undergoing
a study. This is an atypical case. What is your advice?

Best regards,
Alberto Morales Salinas. Cuba
Cardiologo
cardioams at yahoo.es

-- 
Dr. Sergio Dubner
President of Scientific Committee

Dr. Edgardo Schapachnik
President of Steering Committee