Adam lenskyj - health file - dr. paul dorian 12-feb-2010 report page1&2&3of3.pdf

Adam Lenskyj - health file - Dr. Paul Dorian 12-Feb-2010 report page1&2&3of3
A teaching hospital affiliated with the University of Toronto Dr. Aisha LoftersSMH 61 Queen St. EToronto, ON M5C 2T2 Mr. Lenskyj, a 69~year-old retired engineer, was seen in follow-up with respect to coronary arterydisease and atrial flutter while in ICU in the context of urosepsis.
This gentleman has a history of coronary disease, prior inferolateral myocardial infarct, and a PCI tothe right coronary and the left circumflex coronary arteries in 2005 with bare metal stents.
He has a history of controlled hypertension, hypercholesterolemia, and diabetes.
He was clinically stable up until this fa ll when he developed a renal stone and had a uretericprocedure which ultimately was associated with urosepsis and eventually was treated with a rightureteric stent. He did spend about 2 weeks in hospital with urosepsis and some hypotension and acomplicating GI bleed, all of which resolved. Early after hospitalization, he developed atrial flutter.
with ventricular rates of about 150 and ultimately was scheduled for urgent cardioversion butconverted to sinus rhythm on the cardioversion table before the shock was administered. He wasdischarged on Warfarin and beta-blocker and now comes to the office for follow-up. It is nowapproximately 2 months or more since his hospital discharge. He has gradually recovered his physicalstrength and wellbeing and is now able to climb four flights of stairs without dyspnea, presyncope,syncope, palpitations, chest pain, or symptoms suggesting myocardial ischemia or arrhythmias. Hisgeneral wellbeing is good.
His blood pressure has apparently been in good control. He is monitored by the diabetic clinic and ison Metformin 50 mg b.i.d. in this regard.
For his coronary disease, he is on Metoprolol 50 mg b.i.d., Ramipril 5 mg a day, Lipitor 40 mg a day,Warfarin as adjusted, and Norvasc 2.5 mg a day.
Adam Lenskyj - health file - Dr. Paul Dorian 12-Feb-2010 report page1&2&3of3
He had a follow-up upper GI gastroscopy in January 2010 under Dr. Ottaway, and the test apparentlyshowed no ulcers or gastritis. A breath test is now scheduled.
His general wellbeing is good. He is quite anxious about his future risk of recurrent cardiac eventsand safety with respect to travel. He finds the Warfarin a substantial hardship and is particularlyconcerned about difficulties with anticoagulation during planned trips to the Middle East and other farflung places.
Pending this consultation, we did arrange for a persantine Cardiolite scan which showed moderate leftventricular enlargement and a nonreversible lateral wall defect with a lateral hypokinesis but noreversible ischemia demonstrated. The post stress ejection fraction is 38%. I believe this may be anunder estimate of the true EF.
On examination today, the blood pressure is 142/79. The heart rate is 57 per minute and regular. Thechest is clear, and the jugular venous pressure is normal. The heart sounds are distant without addedsounds, and there is a soft basal systolic ejection murmur of mild aortic sclerosis without other addedsounds or murmurs.I should add that he has had a repeat CT scan of the abdomen, and this showed avery small renal stone of 2 mm in diameter, and it is to be followed up by Dr. Pace with an officevisit.
Today's electrocardiogram shows sinus bradycardia, occasional atrial premature beats, andnonspecific ST-T wave changes without acute signs of ischemia.
IMPRESSION:Mr. Lenskyj has had an episode of persistent atrial flutter but which nevertheless stops spontaneouslyin the context of a relatively severe acute illness. One would classify this as "atrial flutter due to apotentially reversible cause," and I believe the future risk of atrial flutter occurrence, although notnegligible, is quite small. I do not think that anti-arrhythmic therapy is indicated. With respect tostroke prevention strategies, he is in CHADS classification of 2 with hypertension and diabetes but isprobably at very low stroke risk given the single episode of atrial flutter from reversible causes, andthus according to guidelines, permanent anticoagulation is probably not indicated.
Given the potential risks of bleeding, the individual risk related to his travel schedule, and theuncertain indication, I have asked him to stop the Coumadin and substitute Aspirin 75 mg daily. I donot believe that the addition of Clopidogrel to Aspirin is required because of the relatively low strokerisk and the additional risk of bleeding. There is a small risk of Gl bleeding with the Aspirin, and Dr.
Ottaway will verify that this is safe to continue at the next clinic visit.
He should of course remain on all his other medications for the secondary prophylaxis of coronaryartery disease. There is no evidence for heart failure, so other medications are not required. We willdo an echocardiogram to get an additional independent measure of LV function since I believe thathis ejection fraction is probably in the 40-50% range.
He is at low-to-moderate risk of a future recurrence of cardiovascular events, and of course we willneed a very close follow-up of his blood pressure, blood sugars, and LDL cholesterol to make surethat It is at target.
Adam Lenskyj - health file - Dr. Paul Dorian 12-Feb-2010 report page1&2&3of3
With permission, I will see him in follow-up in 1 year's time. In the meantime, I have recommendedthat he continue his currently relatively active lifestyle and indeed travel and do more vigorousactivities Ifhe wishes. Thank you for allowing me to participate in his care.
Paul Dorian, MD, FRCPCTel: 416-864-5104Fa" 416-864-5283dorianp@smh.toronto.on.ca Electronically Signed byPaul Dorian, MD, FRPC 22/02/2010 10:52 Jeannette Goguen, MD, FRCPSt Michael's Hospital61 Queen St E, 6th FloorToronto ON M5C2T2 Aisha Kamilah Lofters, MDSmh-family Practice30 Bond StreetToronto ON M5B1W8 Clifford Ottaway, MDSmh 30 Bond St3-bond WingToronto ON M5B1W8 Kenneth Pace, MD, FRCPSmh-61 Queen St ESuite #9-106Toronto ON M5C2T2 D: Feb-12-2010 12:31 P T: Feb-12-2010 PCI678724-616804 Doc: 1527426 Adam Lenskyj DN: cn=Adam Lenskyj, o, ou=P.Eng.,

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