Pharmacotherapy Case Study: Atrial Fibrillation by Dr. Nehad Jaser

Patient Profile: 68-year-old male

Subjective Data

  • Chief Complaint: “My heart feels like it’s fluttering, and I get winded just walking to the mailbox.”

  • History of Present Illness:

    • Intermittent palpitations and shortness of breath for 3 months, worsening over the past 2 weeks.

    • Episodes last 10–30 minutes, occurring 2–3 times weekly, without chest pain or syncope.

    • Fatigue impacting daily activities; lightheadedness reported during episodes.

  • Medical History:

    • Hypertension (10 years), type 2 diabetes (8 years), hyperlipidemia.

    • No prior stroke or heart failure.

  • Medications:

    • Metoprolol tartrate 25 mg BID (admits to missing doses "when I feel fine").

    • Atorvastatin 20 mg daily, metformin 1,000 mg BID.

    • No anticoagulant use.

  • Social History:

    • Former smoker (1 pack/day × 15 years, quit 10 years ago).

    • Alcohol: 3–4 glasses of wine/week.

    • Sedentary lifestyle (desk job, no exercise).

  • Family History: Father with coronary artery disease; mother with hypertension.

Objective Data

  • Vitals:

    • BP: 150/92 mmHg, HR: 128 bpm (irregularly irregular), RR: 20/min, SpO₂: 96% on room air.

    • BMI: 30 kg/m².

  • Physical Exam:

    • Cardiovascular: Irregularly irregular rhythm, no murmurs. JVP 8 cm.

    • Lungs: Clear bilaterally.

    • Extremities: Trace pedal edema.

  • Diagnostic Studies:

    • ECG: Atrial fibrillation with rapid ventricular response (no P waves, irregular R-R intervals).

    • Echocardiogram: Left atrial enlargement (4.5 cm), LVEF 55%, no valvular abnormalities.

    • Labs:

      • TSH: 2.0 mIU/L (normal), K⁺: 4.1 mEq/L, Cr: 1.1 mg/dL (eGFR 68 mL/min/1.73m²).

      • BNP: 250 pg/mL (mildly elevated).

Assessment

  1. Primary Diagnosis:

    • Persistent Atrial Fibrillation with rapid ventricular response.

  2. Stroke Risk:

    • CHA₂DS₂-VASc Score = 4 (Age ≥65, Hypertension, Diabetes).

  3. Bleeding Risk:

    • HAS-BLED Score = 2 (Age ≥65, Hypertension).

  4. Contributing Factors:

    • Poor adherence to metoprolol, alcohol use, obesity.

Pharmacotherapy Plan

  1. Rate Control:

    • Metoprolol tartrate 50 mg BID (titrate to HR <110 bpm at rest).

    • If inadequate response: Add diltiazem 120 mg daily (non-dihydropyridine CCB).

  2. Anticoagulation:

    • Apixaban 5 mg BID (DOAC preferred over warfarin due to renal function and safety profile).

  3. Rhythm Control (if symptomatic):

    • Electrical Cardioversion after 3 weeks of therapeutic anticoagulation.

    • If recurrent: Amiodarone 200 mg daily (antiarrhythmic for structural heart disease).

  4. Comorbidity Management:

    • Optimize BP: Lisinopril 5 mg daily (add if BP remains >130/80 mmHg).

    • Diabetes: Continue metformin; target HbA1c <7%.

Monitoring

  • Weekly: HR, BP, symptoms (palpitations, dyspnea).

  • 3-month follow-up: Renal function, liver enzymes, HbA1c.

  • Annual: Echocardiogram to assess cardiac structure.

Patient Education

  • Adherence: Use pill organizer for metoprolol and apixaban; do not skip doses.

  • Lifestyle: Limit alcohol to ≤1 drink/day, increase physical activity, low-sodium diet.

  • Bleeding Precautions: Report unusual bruising, blood in stool, or headaches.

Rationale

  • Apixaban reduces stroke risk in AF with CHA₂DS₂-VASc ≥2 and has lower bleeding risk than warfarin.

  • Metoprolol controls ventricular rate and improves symptoms; combination with diltiazem may enhance efficacy.

  • Amiodarone is reserved for refractory cases due to long-term toxicity risks (thyroid, pulmonary).

  • Lifestyle modifications address modifiable risk factors (alcohol, obesity) to reduce AF burden.

Key Considerations:

  • Avoid NSAIDs (increase bleeding risk).

  • Monitor renal function annually (apixaban dose adjustment if eGFR <25 mL/min).

  • Refer to cardiology if rhythm control fails (consider ablation).

تعليقات

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