Course Case Studies
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JP is a 76-year-old male with a past medical history significant for coronary artery disease, asthma, hypertension, and hyperlipidemia who presents to the hospital due to complaints of feeling extremely fatigued and having a very fast pounding feeling in his chest. After initial assessment and electrocardiogram, JP is diagnosed with new onset atrial fibrillation and initiated on metoprolol 25 mg orally BID for rate control. After calculating his CHA2DS2-VASc score, the primary team determines that JP is at greater than 2% annual risk of ischemic stroke and requires anticoagulation as well. Prior to admission, JP was taking aspirin 81 mg orally daily, lisinopril 20 mg orally daily, atorvastatin 20 mg orally daily, and an albuterol inhaler as needed.
Study Questions
Based on current guidelines, what anticoagulant(s) should JP be started on?
What other components of his antithrombotic regimen may need to change?
Does JP require any anticoagulant-specific monitoring based on his new medication regimen?
Discussion
According to the 2023 ACC/AHA/ACCP/HRS guidelines for the diagnosis and management of atrial fibrillation, it is recommended that JP be initiated on anticoagulation for prevention of stroke and systemic embolism from atrial fibrillation based on his CHA2DS2-VASc score. As this is nonvalvular atrial fibrillation, first-line therapy includes any of the DOACs (e.g., apixaban, rivaroxaban, dabigatran, or edoxaban), based on their enhanced safety profile over vitamin K antagonists (e.g., warfarin). When selecting a specific agent, edoxaban should be avoided if JP's CrCl is greater than 95 mL/min; however, the remainder of the decision may be based on insurance coverage, patient preference (e.g., once-daily dosing versus twice-daily dosing), drug-interactions, or availability.
Since JP was taking an aspirin for his CAD prior to admission, this must also be addressed. According to the same AF guidelines, monotherapy with an oral anticoagulant alone should be used in patients with CCD and AF in order to decrease the risk of major bleeding. For this reason, JP's aspirin may be discontinued now that he is being started on an oral anticoagulant.
As for specific monitoring, JP will not require routine monitoring with any of the DOACs, another benefit of utilizing these agents over older agents such as warfarin.
- Back to Course Home
- Participation Instructions
- Review the course material online or in print.
- Complete the course evaluation.
- Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.