The medical record states chest pain, hypertension and heart failure. Aditional info received 9/26/03. A death certificate was obtained for the subject. Date of death: 6/8/03. The cause of death was due to ischemic cardiovascular disease. Relevant hisotry section contains cardiology consultation and 2D Echo and Doppler study 2/11/03 and medical history notes 4/23/03 and 2/28/03. The ischemic cardiovascular disease was reported by the investigator as unrelated to the study product. Cardiology consultation 2/11/03. Pt presents today for evaluation prior to undergoing total hip replacement scheduled for 2/20/03. Dr has requested prior to pt undergoing a surgical procedure. Presently pt seems to be doing quite well, with her primary complaint being of hip pain that is now limiting her mobility. Specifically she denies chest discomfort, shortness of brreath, dyspnea on exertion (although she is not able to probably do enough to develop dyspnea), lower extremity swelling, orthopnea, PND, chest discomfort or palpitations. She seems to be complying with her medications fairly well although, as usual, she expresses a desire to "get off them." Current medications: Coumadin, Spironolactone 26mg qd, Lasix 40mg qd, KCI 20meg qd, Coenzyme Q10, 50mg qd, Atacand/HCT 16/12.5mg qd, Triamterene 100mg qd. Physical examination: she is a lean female in no acute distress. Wt was not recorded today, but in late January it was 126.25lbs. P 84 and irregularly irregular.  BP146/72 in the left arm in the seated position using a normal size cuff. HEENT exam reveals normocephatic, atraumatic head. Conjunctiva and lids are clear. Mucus membranes are dry but pink. Neck is supple without lymphadenopathy or thryromegaly. JVP is 9cm with negative HJR. Carotids are 2+ bialterally without brutis. Lungs are clear to auscultation and there is no accessory muscle use in her respiratory effort at rest. Cardiac exam reveals on enlarged an dlaterally displaced apical impulse with an irregularly irregular rhythm and a normal S1, S2. There are no gallops or rubs. There is a 11/V1 systolic murmur at the left lower sternal border which is unchanged. Extremities reveal no edema, and the peripheral pulses are 2+ and symmetric throughout. A 12-lead lectrocardiogram was obtained at hte time of her visit. This revealed atrial fibrillation with a controlled ventricular response of 80 beats/minute. She has a left anterior fascicular block, and LVH with secondary QRS widening and repolarization abnormalities. Since her last tracing dated 4/12/02 her heart rate was decreased by 10 beats/minute, but otherwise there are no significant changes. Also at the time of her visit, she underwent a 2D echo and doppler study which is reported separately. Impressions: 1) hypertension iwth hypertensive cardiomyopathy. The hypertension is relatively well controlled at this time. In addition, it is noted that her heart failure, which was rather severe back in April of last year, has improved significantly since then. More than likely this is due to the addition of Spironolactone and Atacand to her medical regimen. 2) Bialteral hip osteoarthritis with the left being worse than the right. She is scheduled to undergo surgery for hip replacement in ten days. I will forward a letter the Dr with specific recommendations regarding ways to minimize potential adverse events related to the pt's cardiac dysfunction perioperatively. Plan: 1) Continue current medications at their current dosages with the exception of Coumadin which will be discontinued seven days prior to this surgery with the substitutionof IV heparin for the Coumadin three days prior to the surgery. 2) Start Toprol XL 12.5 mg qhs today, and continue for at least one month following this surgery. 3) Return for follow-up with me in six to eight weeks. 2D echo and doppler study 2/11/03. Indication: heart failure. Bialteral atrial enlargement with a left atrial internal dimension of 48mm in the parastenal long axis view. Concentric left ventricular hypertrophy with left ventricular enlargement and moderately severe systolic dysfunction which is likely due to hypertensive cardiomyopoathy. The LVEF today is measured at 37 percent which is an improvement from 10 to 15 percent measured approxximately ten months ago. Right ventricular enlargement with normal systolic function. Aortic valve with normal leaflets but annular calcification. There is mild AR but no AS. Mitral valve with normal anterior mitral leaflet, but the posterior leaflet is somewhat limited in its mobility. There is mitral annular calcification and moderate mitral regurgitation which is due to the abnormal posterior leaflet. Normal tricuspid valve with moderate TR and moderately elevated PA systolic pressure of 51mm/Hg. Medical history notes: 4/23/03. Pt returned for follow-up of heart failure and hypertension. Actually follow-up was specifically requested by Dr due to worsening symptoms of chest pain. Sine her last visit the pt reports the occurrence of chest pain about once a week at random times. There is no relationship to exercise or time of day. She denies SOB, dyspnea on exertion, rhythm disturbance, orthopnea, PND, anorexia, early satiety and lower extremity swelling. She does report chest pain/discomfort. She denies nausea, vomiting, diarrhea, diaphoresis or pleuritic pain. She is planning a trip on 5/9/03. Current medications: Coumadin, Spironolactone 25mg qd, Lasix 40mg qd, KCI 20meg qd, Coenzyme Q10, 50mg qd, Atacand/HCT, 16/12.5mg qd, multivitamin one qd, Synthroid 25mcg qd. A 12-lead electrocardiogram was obtained at the time of her visit which revealed atrial fibrillation with a ventricular response at 80, normal axis, a left anterior fascicular block and normal QT interval. Sine her last tracing dated 2/11/03 there are no significant changes. Impression: chest pain. Given atypical pattern and character, suspect non-cardiac etiology. Heart failure. Remarkably stable. Hypertension. Relatively well controlled on current medications. Plan: samples of Protonix 40mg one po qam. Follow up on Monday 4/28/03 at 8:30am. If chest pain is unimproved with the addition of proton pump inhibitor, will likely refer for adenosine sestamibi vs dobutamine echo (non-exercise due to severe osteoarthritis). Medical history notes: 4/28/03: Pt returned for follow-up of chest pain. At her last visit (4/23/03) I started her on Protonix, 40mg qd, based on the suspicion that the chest pain might be due to GERD. Since her last visit she reports definite decrease in her chest pain. Current mecication: Coumadin, Spironolactone 25mg qd, Lasix 40mg qd, KCI 20mcg qd, Coenzyme Q10, 50mg qd, Atacand/HCT 16/12.5mg qd, multivitamin one qd, Synthroid 25mcg qd, Protonix 40mg qd. Impression: chest pain. Improved significantly after five days of Protonix. Plan: continue Protonix, 40mg qd for four weeks (total), then 40mg qod for four weeks, then discontinue. Follow up in two months. Note to Dr. Autopsy report received on 10/01/2003 states COD was cardiovascular disease.