# A Case of New-Onset Atrial Tachyarrhythmias With Apical Hypertrophic Cardiomyopathy and Bronchiectasis in a Very Elderly Patient: A Therapeutic Dilemma

## TL;DR

This case study explores the challenges of treating a 98-year-old patient with heart and lung conditions, where managing atrial fibrillation without anticoagulation posed a significant dilemma.

## Contribution

The paper presents a unique clinical case highlighting therapeutic challenges in managing AF in a patient with ApHCM and bronchiectasis.

## Key findings

- Electrical cardioversion successfully converted AF to sinus rhythm without anticoagulation.
- Anticoagulation was avoided due to the high risk of hemoptysis in the patient with bronchiectasis.
- The case emphasizes the need for individualized treatment strategies in patients with complex comorbidities.

## Abstract

Hypertrophic cardiomyopathy (HCM) is a primary myocardial disease that is genetically transmitted as an autosomal dominant trait. Even apical HCM (ApHCM) induces atrial fibrillation (AF) based on underlying left ventricle (LV) diastolic dysfunction, where anticoagulation therapy is recommended. However, anticoagulation for AF in patients at high risk of bleeding is a double-edged sword. A 98-year-old woman living in a nursing home presented to our hospital with sudden-onset dyspnea and palpitation persisting for two hours. The patient had a history of apical HCM and bronchiectasis. An electrocardiogram showed a regular tachycardia with a heart rate of 130 bpm, suggesting atrial flutter with 2:1 atrioventricular conduction. Intravenous verapamil (5 mg) resulted in the conversion into AF, and subsequent cibenzoline (70 mg) failed to restore sinus rhythm. Given the impossibility of continuous anticoagulation, electrical cardioversion was planned. Electrical cardioversion was successful in converting AF into sinus rhythm. Given the very high risk of hemoptysis, anticoagulation was avoided. This case gives an insight into how to manage a practical therapeutic problem, which is the coexistence of AF and bronchiectasis. A variety of individual factors should be considered for clinical decision-making and management of patients with concomitant HCM and AF.