A 74-year-old man with New York Heart Association Class IV and Stage D heart failure secondary to ischemic cardiomyopathy requiring left ventricular assist device (LVAD) implantation as destination therapy, recurrent driveline infections necessitating lifelong antibiotics, paroxysmal atrial fibrillation, transient ischemic attack, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, hypothyroidism, depression, anxiety, and insomnia presents with a four day history of recurrent falls at home and is admitted to the hospital after a witnessed syncopal episode resulting in another ground level fall with head trauma. Family describes event as patient's eyes rolling backwards followed by small jerking behavior involving both upper and lower extremities. There was no concurrent tongue biting, bowel or bladder incontinence, or focal neurologic deficits, and the patient denied any preceding cardiac or respiratory complaints. He has been healthy recently without infectious symptomatology, bleeding, or changes in appetite.

On paramedic arrival, the patient was neurologically intact with a Glasgow Coma score of 15. In the emergency department he was afebrile with an initial mean arterial blood pressure of 78 (measured by doppler ultrasound). Heart rate was in the low 100s, respiratory rate between 15-20 breaths/minute, and oxygen saturations 95% on room air. Glucose levels were within normal range.

Other than minor superficial abrasions to bilateral knees, there were no overt traumatic injuries on physical assessment. Cardiac, lung, abdominal and neurologic examinations were unremarkable.

An extensive work up was pursued in the emergency department. Pacemaker interrogation did not display any concerning arrhythmic events over the last 24 hours. Electrocardiogram (ECG) revealed a ventricularly paced rhythm and a chronically prolonged QTc without new ischemia, arrhythmias, or overall changes compared to previous ECGs. Complete blood count was notable for anemia (hemoglobin of 12), consistent with the patient's baseline levels. Comprehensive metabolic panel demonstrated appropriate kidney function and no electrolyte abnormalities. International normalized ratio (INR) was in therapeutic range. Urinalysis and chest x-ray were negative for infection. Computed tomography of his head was unremarkable for acute intracranial pathology. Although mean arterial pressures were not consistent with orthostatic hypotension, the patient did endorse symptoms of dizziness while standing.

He was admitted to the cardiac transplant service and underwent a two-day hospitalization for telemetry monitoring and further testing.

Patient's home medications were reviewed and included the following: amiodarone, aspirin, cephalexin, cholecalciferol, calcium, ferrous sulfate, gabapentin, hydrocodone, levothyroxine, losartan, methocarbamol, metoprolol succinate, mexiletine, pantoprazole, pravastatin, spironolactone, trazadone, venlafaxine, and warfarin. Family assists with daily administration of the patient's medications and assure no recent dose changes or lack of adherence.

While echocardiogram demonstrated global hypokinesis of the left ventricle, findings were chronic in nature without dynamic changes compared to previous imaging. Serial LVAD interrogations did not display any functional abnormalities or alarms, continuous cardiac monitoring was unrevealing for arrhythmias, and routine labs revealed no gross changes.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Dyslipidemia, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Lipid Metabolism, Novel Agents, Statins, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support, Interventions and Imaging, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Hypertension

Keywords: Heart-Assist Devices, Arterial Pressure, Calcium, Fludrocortisone, Gabapentin, Hydrocodone, International Normalized Ratio, Losartan, Methocarbamol, Metoprolol, Mexiletine, Midodrine, Pantoprazole, Pravastatin, Spironolactone, Thyroxine, Venlafaxine Hydrochloride, Warfarin, Heart Ventricles, Heart Rate, Atrial Fibrillation, Dizziness, Hyperlipidemias, Hypotension, Orthostatic, Ischemic Attack, Transient, Reference Values, Respiratory Rate, Tilt-Table Test, X-Rays, Heart Failure, Heart Transplantation, Electrocardiography, Amiodarone, Syncope, Pulmonary Disease, Chronic Obstructive, Neurologic Examination, Electroencephalography, Emergency Service, Hospital, Ultrasonography, Doppler, Lower Extremity, Cholecalciferol, Hospitalization, Hypothyroidism, Cardiomyopathies, Craniocerebral Trauma, Hypertension, Anti-Bacterial Agents, Cephalexin, Pacemaker, Artificial, Tomography, Ischemia, Telemetry, Hospitals, Anxiety, Aspirin, Glucose, Geriatrics

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