A 27-year-old Caucasian male professional rugby player with signs of decompensated heart failure

28 January 2020

Organised by:

The case

A 27-year-old Caucasian male professional rugby player was admitted to his local district general hospital with signs and symptoms of decompensated heart failure.

He admitted to regularly taking cocaine and performance enhancing steroids. He had no other significant past medical history.

His ECG showed atrial fibrillation (AF), (Figure 1).
A transthoracic echocardiogram revealed bi-atrial dilatation and a dilated left ventricle (LV) with moderate to severe LV systolic dysfunction.
He was acutely managed with intravenous diuretics and initiated on evidence-based heart failure medications including beta-blockers and angiotensin converting enzyme (ACE) inhibitors.
Once stabilised he was discharged on bisoprolol 2.5 mg, ramipril 5 mg and rivaroxaban, a non-vitamin K antagonist.

In view of his drug history a diagnosis of drug-induced dilated cardiomyopathy (DCM) was made.

Figure 1: Admission ECG showing atrial fibrillation

References

1. Kotecha, D. and J.P. Piccini, Atrial fibrillation in heart failure: what should we do? European Heart Journal, 2015. 36(46): p. 3250-3257.1. Kotecha, D. and J.P. Piccini, Atrial fibrillation in heart failure: what should we do? European Heart Journal, 2015. 36(46): p. 3250-3257.

2. Kirchhof, P., et al., 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J, 2016. 37(38): p. 2893-2962.

3. Echt, D.S., et al., Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med, 1991. 324(12): p. 781-8.

4. Zipes, D.P., et al., Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 9: Arrhythmias and Conduction Defects: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol, 2015. 66(21): p. 2412-2423.

5. Pelliccia, A., et al., Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis: position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology (EAPC). Eur Heart J, 2019. 40(1): p. 19-33.

6. Holmes, D.R., Jr., M. Alkhouli, and V. Reddy, Left Atrial Appendage Occlusion for The Unmet Clinical Needs of Stroke Prevention in Nonvalvular Atrial Fibrillation. Mayo Clin Proc, 2019. 94(5): p. 864-874.

7. Sharma, S.P., P. Park, and D. Lakkireddy, Left Atrial Appendages Occlusion: Current Status and Prospective. Korean Circ J, 2018. 48(8): p. 692-704.

8. Reddy, V.Y., et al., Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-Year Follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) Trial. Circulation, 2013. 127(6): p. 720-9.

9. Holmes, D.R., Jr., et al., Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol, 2014. 64(1): p. 1-12.

10. Holmes, D.R., Jr., et al., Left Atrial Appendage Closure as an Alternative to Warfarin for Stroke Prevention in Atrial Fibrillation: A Patient-Level Meta-Analysis. J Am Coll Cardiol, 2015. 65(24): p. 2614-2623.

Notes to editor

Authors information:

Dr. Andre Briosa e Gala, Oxford University Hospital NHS Foundation Trust
Dr. Andrew Cox, Oxford University Hospital NHS Foundation Trust
Dr. Tim Betts, Oxford University Hospital NHS Foundation Trust