- Atrial fibrillation with slow ventricular response
- Left axis deviation (LAD)
- Left bundle branch block (LBBB)
Here there is atrial fibrillation, and the ventricular response is very slow, suggesting that there is conduction delay in the AV Node or His bundle as well as in the left bundle branch. Alternatively he may be taking AV-nodal blocking drug (e.g. beta-blocker, verapamil/diltiazem, digoxin).
What to do?
It is always important to establish the cause of heart failure. The most important causes of LBBB are ischaemia, aortic stenosis and cardiomyopathy.
In this patient an echocardiogram will show whether he has significant valve disease and how impaired his left ventricular function is. In the absence of pain, coronary angiography is probably not indicated.
The heart failure needs to be treated with diuretics and an angiotensin-converting enzyme inhibitor, but digoxin must be avoided as it may slow the ventricular response still further. He almost certainly needs a permanent pacemaker.