Brief Answer:
i would explain as follows:

Detailed Answer:
Hello!

Welcome and thank you for asking on HCM!

I understand your concern and would like to explain that his actual clinical conditions seem to be complex.

Facing a persistent atrial fibrillation with actual dysphagia and altered clinical status (varying BP values, difficulty in breathing, uncontrolled ventricular rate of atrial fibrillation, white lips, and furthermore presence of asbestosis) it is important to perform a differential diagnosis:

a) An investigation for a possible cerebral vascular ischemia with neurological sequelae (such as dysphagia and other possible focal neurological deficits) should be performed by a careful neurological status evaluation (neurologist consultation) and underlying medical tests (brain CT or MRI).

b) As he has a chronic pulmonary disease (asbestosis) and atrial fibrillation, cardio-pulmonary insufficiency should be explored to identify the cause of dyspnea and the level of implication on actual altered physical status.

- A careful physical exam,
- resting ECG, chest X ray study,
- cardiac ultrasound,
- complete blood count and PCR,
- arterial blood gas analysis
- blood electrolytes
- fasting glucose,
- AST&ALT,
- urea, creatinine, etc

are necessary to rule in/out serious pulmonary dysfunction, severely decreased cardiac performance (heart failure), an important acid-base and hydro-electrolytic or metabolic disorder, an acute inflammation/infection, etc.

c) According to the results of the above tests and examinations, a better understanding of the etiological factors responsible for the actual clinical status could be achieved, so an appropriate subsequent therapy prescribed.

- If a superimposed pulmonary inflammation/infection is responsible, a properly instituted antibiotics therapy, bronchodilators, and respiratory assistance would be helpful.

- If a decreased cardiac function is the cause, a better optimization of heart failure managements would improve clinical outcomes (an appropriate diuretics regimen, controlling high blood pressure by adding vasodilators such as ACEI (ramipril, lisinopril, et), ARB (valsartan, irbesartan, telmisartan, etc), and adjusting the medication for atrial fibrillation control (if no contraindications exist to use alternative heart rate control drugs (beta-blockers in i/v route, or digitalis, or even intravenous calcium channel blockers such as diltiazem or verapamil, etc) avoiding so the need for oral medications (at least as the dysphagia disorder is completely explored.

- Regarding his actual medications, I would explain that when diltiazem caplules are opened, attention should be paid to avoid those micro-granules disruption, as it may delay drug absorption and decrease its pharmacological effects.

- If no contraindications exist (after neurological investigations), it is necessary to start an alternative anticoagulant for prevention of thrombo-embolic events from atrial fibrillation (as he has a considerable risk for this accidents [CHA2DS2 VASC score >2 points], possibly 4 points (if cerebro-vascular accident is confirmed). A subcutaneous low molecular weight heparin such as enoxaparin, fondaparinux, etc, and if dysphagia resolved new OACs such as apixapan, rivaroxaban, would be advisable.

At the end, only after a thorough investigation is performed, it would be possible to conclude his prognosis, if there are good chances for improvement or the situation is terminal.

I hope and wish that everything is going to be OK!

If you have concrete tests results, I would be happy to give my professional opinion.

Hope to have been helpful to you.

Feel free to ask me whenever you need!

Kind regards,

Dr. Iliri

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