Aortic Stenosis with A Fib and CHF

This case is written by Dr. Donika Orlich. She is a staff physician practising in the Greater Toronto Area. She completed her Emergency Medicine training at McMaster University along with a fellowship in Simulation and Medical Education.

Why it Matters

The management of patients with aortic stenosis can be tenuous at the best of times. When these patients present with CHF or dysrhythmias, their management is much more nuanced than the typical patient presenting with the same complaints. This case nicely highlights the following management differences:

The need for expedient rate control in a patient with aortic stenosis (in this case, most safely accomplished via cardioversion)
The need for judicious treatment of CHF, including careful diuresis and avoiding nitroglycerin use
The importance of early consultation with both cardiac surgery and cardiology

Clinical Vignette

A 78-year-old male presents via EMS with 4 days of increased SOB. The triage nurse comes to tell you she has put him in the resuscitation bay due to unstable vitals. HR was in the 150s. The O₂SAT was 86% on RA when EMS arrived, but is now 95% on a NRB.

Case Summary

A 78-year-old male presents with increased SOB over the past 4 days. A recent ECHO will be presented showing severe AS. The ECG will demonstrate new A Fib with a HR of 150 and the CXR will show CHF. The patient will be normotensive at first but will become hypotensive shortly after. The team will then need to decide whether to cardiovert the patient or attempt rate control. If these are done safely, the patient will respond and then develop worsening CHF. Definitive management should be sought with early cardiology/cardiac surgery consult. If management is not carried out judiciously, the patient will become profoundly hypotensive.