The patient, a 90-year-old Caucasian male with a PMH of AF, PVD, vision loss, HLD, obesity type I, SOB, and CHF was admitted to hospice on 05/21/21 for systolic congestive failure. Clinically, according to the SAF scale: class 4 (CHF due to AF). According to the CHA2DS2-VASc score, the patient has 2 points (age >75 years), arterial hypertension 1 point (BP 143/72 mmHg), congestive heart failure 1 point, and vascular disease 1 point. Sum: 5 points (>2 for men) which means the constant intake of anticoagulants is strongly recommended (moderate-high risk of stroke). HAS-BLED score: 1 point (age>65), low risk for major bleeding. The combo calculator assessed the 5-year risk of stroke to be 13%, and the 5-year risk of stroke or death to be 93%.
The anamnesis lacks the number of episodes of atrial fibrillation. The essential instrumental tests should be done before prescriptions: ECG (P is absent, F-waves instead), heart ultrasound, and Holter monitoring (Craig et al., 2019). Before prescribing anticoagulants, the patient needs to take a clinical blood analysis (excluding anemia), check the gastrointestinal tract, liver enzymes, kidney functions (creatinine, ALT, ACT, bilirubin), clinical urine analysis (excluding erythrocyturia and albuminuria).
According to the risk scores, the patient needs anticoagulant medications. The patient does not have a mechanical valve or hemodynamically significant mitral stenosis, so no limitations for NOACs, which might be more practical compared to warfarin (no dietary limitation and INR monitoring). Also, warfarin in meta-analyses did not show a reduction in death rates, ischemic events, or strokes but increased the rate of major bleeding (Craig et al., 2019). Moreover, NOACs compared to warfarin, represented an advance in therapeutic safety according to the latest AF guidelines (Craig et al., 2019). The level of the patient’s CrCl is unknown from anamnesis; however, one of the following NOACs can be prescribed in the relevant doses: Tabl. Dabigatran 150 mg 2 per day (renally excreted, if CrCl < 30 ml/min, cannot be taken) or tabl. Rivaroxaban 15 mg once daily (CrCl should be > 30 ml/min) or tabl. Apixaban 5 mg twice daily (predominantly eliminated hepatically, a drug of choice).
NOACs should be recommended to the patient in terms of fewer drug-drug interrelations, and fewer risks of intracranial bleeding than warfarin. However, if the patient is concerned financially and accepts dietary limitations and repeated INR testing, it is not necessary to start with NOACs. Still, it is important to discuss with a patient all the possible options and implement tailored education for the patient in oral anticoagulation intake (Hawes, 2018). Warfarin is prescribed from a small dosage (lower than 10 mg) with a gradual increase to the final aim of INR 2,0-3,0.
The duration and form of atrial fibrillation play a role in the further tactics. On this occasion, the length of atrial fibrillation is unknown. Then, the peroral intake of anticoagulants for 3 weeks is recommended (warfarin with INR control or NOACs) (Bosch et al., 2018). Afterward: if no clots are found in the left atrium on echoCG, implement cardioversion with monitoring of the heart rate deviations and prolonged intake of anticoagulants. Controlling ventricular rate is also important in AF with HR < 80 bpm (patient has 72 bpm): beta-blocker or nondihydropyridine calcium channel antagonist is recommended (Craig et al., 2019). Currently, the patient has pleural effusion, so the latter is not the primary therapeutic choice also due to the negative inotropic effect. A selective beta-blocker, such as metoprolol tartrate 50 mg twice per day, can be the choice therapy if the patient has no AV blockade II-III, bradycardia, SSS.
Cardizem or other calcium-blockers are not recommended for patients with peripheral vessel diseases as this group of drugs decreases the peripheral restriction of the vessels and worsens the symptoms of CHF, such as edema and pleural effusion (Pariaut, 2017). The patient already had an episode of pleural effusion, so deterioration of the current condition might not be rational on this occasion. While solving the case study, no personal patient documentation was used according to HIPPA guidelines (HIPPA guidelines materials, 2021).
References
Bosch, N. A., Cimini, J., & Walkey, A. J. (2018). Atrial fibrillation in the ICU. Chest, 154(6), 1424-1434.
Craig, T. J., Wann, L. S., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Furie, K. L., & Heidenreich, P. A. (2019). 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Journal of the American College of Cardiology, 74(1), 105-132.
Hawes, E. M. (2018). Patient education on oral anticoagulation. Pharmacy, 6(2), 1-10.
HIPPA guidelines materials.Health Information Privacy.
Pariaut, R. (2017). Atrial fibrillation: Current therapies. Veterinary Clinics of North America: Small Animal Practice, 47(5), 977-988.