CLINICAL CASES. Atrial Fibrillation Case Study #2 ► An 81-year-old white female with a history of chronic, non-valvular AF, a history of a previous ischemic.

CLINICAL CASESCLINICAL CASES

Atrial Fibrillation Atrial Fibrillation Case Study #2Case Study #2

► An 81-year-old white female with a history of An 81-year-old white female with a history of chronic, non-valvular AF, a history of a chronic, non-valvular AF, a history of a previous ischemic stroke, and a history of mild previous ischemic stroke, and a history of mild congestive heart failure has been on a congestive heart failure has been on a combination of clopidogrel and aspirin therapy combination of clopidogrel and aspirin therapy because she was found to be intolerant of because she was found to be intolerant of warfarin. warfarin.

► She is on a proton pump blocker, an ACE She is on a proton pump blocker, an ACE inhibitor, a diuretic, and digoxin.inhibitor, a diuretic, and digoxin.

► She is admitted to the hospital for a GI bleed, She is admitted to the hospital for a GI bleed, and is found to have a hematocrit of 29 and a and is found to have a hematocrit of 29 and a hemoglobin of 9.8. The aspirin and clopidogrel hemoglobin of 9.8. The aspirin and clopidogrel are discontinued.are discontinued.


The patient stabilizes, and the cardiologist is The patient stabilizes, and the cardiologist is consulted to determine the subsequent course consulted to determine the subsequent course of her antithrombotic treatment. She has a of her antithrombotic treatment. She has a HAS-BLED score of 3.HAS-BLED score of 3.

It is your opinion that:It is your opinion that: 1)1) Because of the documented GI bleed, the patient Because of the documented GI bleed, the patient

should not be treated with antithrombotic agents, should not be treated with antithrombotic agents, because the risk of bleeding outweighs the risk of because the risk of bleeding outweighs the risk of stroke and its complications.stroke and its complications.

2)2) Because of the patient's risk profile, there should Because of the patient's risk profile, there should be an attempt to provide thromboprophylaxis be an attempt to provide thromboprophylaxis against embolic stroke.against embolic stroke.


The cardiologist has determined that this The cardiologist has determined that this patient requires antithrombotic patient requires antithrombotic management for stroke prevention. management for stroke prevention.

At this point you would most likely:At this point you would most likely: 1)1) Try the patient on warfarin againTry the patient on warfarin again

2)2) Try to re-introduce clopidogrel and aspirinTry to re-introduce clopidogrel and aspirin

3)3) Treat the patient with aspirin aloneTreat the patient with aspirin alone

4)4) Introduce a non-monitored oral Introduce a non-monitored oral anticoagulant to the patient's regimen. anticoagulant to the patient's regimen.


► An 82-year-old man with hypertension An 82-year-old man with hypertension and diabetes has permanent atrial and diabetes has permanent atrial fibrillation.fibrillation.

► He has a history of spinal stenosis and He has a history of spinal stenosis and walks with a walker and has a history of walks with a walker and has a history of falls.falls.

► He has a CHADS-VASc score of 3, and a He has a CHADS-VASc score of 3, and a HAS—BLED score of 2.HAS—BLED score of 2.

► Which regimen would you prescribe for Which regimen would you prescribe for prophylaxis against thromboembolism?prophylaxis against thromboembolism?

Which regimen would you prescribe for Which regimen would you prescribe for prophylaxis against thromboembolism?prophylaxis against thromboembolism?

1.1. Warfarin (INR 2.0-3.0)Warfarin (INR 2.0-3.0)

2.2. Warfarin (INR 1.5-2.0)Warfarin (INR 1.5-2.0)

3.3. Aspirin 81 mg dailyAspirin 81 mg daily

4.4. Aspirin 81 mg + clopidogrel 75 mg dailyAspirin 81 mg + clopidogrel 75 mg daily

5.5. An oral Factor Xa or direct thrombin An oral Factor Xa or direct thrombin inhibitorinhibitor


Atrial Fibrillation Case StudyAtrial Fibrillation Case StudyAnticoagulation in Patients at Risk of FallsAnticoagulation in Patients at Risk of Falls

“…persons taking warfarin must fall about 295 (535/1.81) times in 1 year for warfarin

not to be the optimal therapy…”

A 71-year-old man with AF, heart failure, and a prior history of stroke presents with unstable angina and proceeds to cardiac catheterization where a culprit lesion is identified. Optimal management includes:

1) Placement of a drug-eluting stent with plan to continue anticoagulation in addition to 1 year of dual antiplatelet therapy

2) Placement of a drug-eluting stent with 1 year of dual antiplatelet therapy alone

3) Placement of a bare metal stent with plan to continue anticoagulation in addition to 1 month of dual antiplatelet therapy

4) Placement of a bare metal stent with 1 month of dual antiplatelet therapy alone


A 67-year-old female with a history of mitral stenosis with subsequent mechanical mitral valve replacement has AF.

Which of the following anticoagulants can be used for stroke prevention in this patient?

1) Warfarin

2) Dabigatran

3) Apixaban

4) Rivaroxaban

5) All of the above


The major potential benefits of the new The major potential benefits of the new non-monitored oral anticoagulants non-monitored oral anticoagulants include:include:

1)1) Rapid therapeutic anticoagulant effectRapid therapeutic anticoagulant effect

2)2) Greater safety with regards to intracranial Greater safety with regards to intracranial hemorrhagehemorrhage

3)3) Proven reversal agentProven reversal agent

4)4) All of the aboveAll of the above

5)5) Both 1 and 2Both 1 and 2

Atrial Fibrillation Atrial Fibrillation Knowledge Assessment Question Knowledge Assessment Question

An 82-year-old man with AF has had several An 82-year-old man with AF has had several admissions over the past 6 months for heart admissions over the past 6 months for heart failure complicated by worsening renal function. failure complicated by worsening renal function. His creatinine clearance is currently 20 mL/min His creatinine clearance is currently 20 mL/min but frequently fluctuates to 10-15 mL/min. He has but frequently fluctuates to 10-15 mL/min. He has a HAS-BLED score of 3.a HAS-BLED score of 3.

The best anticoagulant regimen for stroke The best anticoagulant regimen for stroke prevention is:prevention is:

1)1) Dabigatran 150 mg twice dailyDabigatran 150 mg twice daily

2)2) Dabigatran 75 mg twice dailyDabigatran 75 mg twice daily

3)3) Warfarin titrated to goal INR 2-3Warfarin titrated to goal INR 2-3

4)4) Rivaroxaban 20 mg once dailyRivaroxaban 20 mg once daily

5)5) Rivaroxaban 15 mg once dailyRivaroxaban 15 mg once daily


A 79-year-old woman with a CHADS-VASc score of 2 who has been on warfarin for the past 2 years returns to clinic for routine follow-up.

Her INR control has been excellent and she has never experienced a stroke or had significant bleeding. Her HAS-BLED score is 2.

Her complaints today are thinning hair, cold intolerance, and fatigue.

Her laboratory work is normal including a TSH.


Which of her symptoms could be due to warfarin?

1) Thinning hair

2) Cold intolerance

3) Fatigue

4) Both 1 and 2

5) All of the above


A 69-year-old woman with AF and CHADS2 score of 4 has a creatinine clearance that is stable at 40 mL/min.

Which of the following anticoagulation regimens are suitable for her?

1) Dabigatran 150 mg twice daily


3) Rivaroxaban 20 mg once daily


5) Both 1 and 4


What would her options be if her creatinine clearance was stable at 25 mL/min?



3) Only warfarin can be used in patients with creatinine clearance < 30 mL/min

4) Both 1 and 2


A 74-year-old man with AF on dabigatran is involved in a motor vehicle accident and needs emergency surgery.

It is unclear if he is taking this medication but the surgeon is concerned about operating on him if he is fully anticoagulated.


Which of the following lab tests, if normal, would reassure the team that the patient is not anticoagulated?

1) INR (international normalized ratio)

2) aPTT (activated partial thromboplastin time)

3) PT (prothrombin time)

4) Bleeding time


A 60-year-old man with AF has been on warfarin but it has been very difficult to control his INR. You have decided to switch to dabigatran. Which of the following is true regarding transitioning a patient from warfarin to dagibatran?

1) Start dabigatran when his INR < 3

2) Start dabigatran when his INR < 2

3) Start dabigatran 24 hours after his last dose of warfarin


What if you decided to switch the patient to rivaroxaban?

1) Start rivaroxaban when his INR < 3

2) Start rivaroxaban when his INR < 2

3) Start rivaroxaban 24 hours after his last dose of warfarin


A 78-year-old female with AF, systolic heart A 78-year-old female with AF, systolic heart failure, hypertension, diabetes, and a history of failure, hypertension, diabetes, and a history of significant GI bleeding has been on warfarin for significant GI bleeding has been on warfarin for many years but has had a difficult time many years but has had a difficult time controlling her INR with frequent controlling her INR with frequent supertherapeutic values despite intensive supertherapeutic values despite intensive monitoring and titration of her warfarin dose. monitoring and titration of her warfarin dose. Her HAS-BLED score is 3. The best treatment Her HAS-BLED score is 3. The best treatment option for her is:option for her is:

1)1) No antithrombotic therapyNo antithrombotic therapy

2)2) Discontinue warfarin and start aspirinDiscontinue warfarin and start aspirin

3)3) Discontinue warfarin and start dabigatran Discontinue warfarin and start dabigatran

4)4) Discontinue warfarin and start rivaroxaban Discontinue warfarin and start rivaroxaban

5)5) Discontinue warfarin and start apixabanDiscontinue warfarin and start apixaban


A 76-year-old woman with heart failure, hypertension, diabetes, and declining renal function (creatinine clearance 35 mL/min) has an embolic stroke due to newly diagnosed AF. She refuses to take warfarin.

What is the best validated antithrombotic regimen in this particular patient?

1)1) Aspirin Aspirin

2)2) Aspirin and clopidogrelAspirin and clopidogrel

3)3) Dabigatran Dabigatran

4)4) Apixaban Apixaban

5)5) RivaroxabanRivaroxaban


A 68-year-old man with a mechanical mitral A 68-year-old man with a mechanical mitral valve develops AF. valve develops AF.

The best anticoagulant option for him isThe best anticoagulant option for him is::

1)1) WarfarinWarfarin

2)2) DabigatranDabigatran

3)3) ApixabanApixaban


5)5) AspirinAspirin


A 76-year-old man with heart failure and A 76-year-old man with heart failure and hypertension undergoes successful catheter hypertension undergoes successful catheter ablation for symptomatic AF. ablation for symptomatic AF.

Which of the following is true regarding his Which of the following is true regarding his anticoagulation management?anticoagulation management?

1)1) He no longer requires anticoagulation now that he He no longer requires anticoagulation now that he is in sinus rhythmis in sinus rhythm

2)2) Patient should be on both aspirin and an Patient should be on both aspirin and an anticoagulantanticoagulant

3)3) Patient should be on an anticoagulant alonePatient should be on an anticoagulant alone

4)4) Aspirin and clopidogrel together is as effective as Aspirin and clopidogrel together is as effective as anticoagulation in these patientsanticoagulation in these patients


The cardiologist has determined that this The cardiologist has determined that this patient requires antithrombotic patient requires antithrombotic management for stroke prevention. At management for stroke prevention. At this point you would most likely:this point you would most likely:

1)1) Try the patient on warfarin againTry the patient on warfarin again

2)2) Treat the patient with aspirin aloneTreat the patient with aspirin alone

3)3) Introduce the non-monitored oral anticoagulant, Introduce the non-monitored oral anticoagulant, apixaban, into the patient's regimenapixaban, into the patient's regimen

4)4) Introduce dabigatran into the patient’s regimenIntroduce dabigatran into the patient’s regimen

5)5) Introduce rivaroxaban into the patient’s regimenIntroduce rivaroxaban into the patient’s regimen


► A 75-year-old male with a history of A 75-year-old male with a history of chronic, non-valvular AF, diabetic renal chronic, non-valvular AF, diabetic renal disease, previous history of ischemic disease, previous history of ischemic stroke, history of mild HF, and controlled stroke, history of mild HF, and controlled hypertension has been on warfarin hypertension has been on warfarin therapy. The HAS-BLED score is 4.therapy. The HAS-BLED score is 4.

► For the past 6 months, despite repeated For the past 6 months, despite repeated visits for monitoring and warfarin dose visits for monitoring and warfarin dose adjustment, his INR has varied between adjustment, his INR has varied between 1.5 and 4.3. 1.5 and 4.3.

► His estimated GFR is 30His estimated GFR is 30 mL/min mL/min..


At this point you would: 1)1) Continue to try to stabilize his INR on warfarinContinue to try to stabilize his INR on warfarin

2)2) Change to aspirin aloneChange to aspirin alone

3)3) Introduce the non-monitored oral anticoagulant Introduce the non-monitored oral anticoagulant rivaroxaban into the patient's regimenrivaroxaban into the patient's regimen

4)4) Introduce the non-monitored oral anticoagulant Introduce the non-monitored oral anticoagulant apixaban into the patient's regimenapixaban into the patient's regimen

5)5) Introduce the non-monitored oral anticoagulant Introduce the non-monitored oral anticoagulant dabigatran into the patient's regimendabigatran into the patient's regimen


► An 82-year-old man with hypertension, An 82-year-old man with hypertension, diabetes, mild congestive heart failure, diabetes, mild congestive heart failure, and previous ischemic stroke, is and previous ischemic stroke, is diagnosed with atrial fibrillation.diagnosed with atrial fibrillation.

► He has not been taking any He has not been taking any anticoagulants.anticoagulants.


Which regimen would you initiate for Which regimen would you initiate for prophylaxis against stroke?prophylaxis against stroke?

1)1) Warfarin (INR 2.0-3.0)Warfarin (INR 2.0-3.0)

2)2) Aspirin 81 mg + clopidogrel 75 mg dailyAspirin 81 mg + clopidogrel 75 mg daily





► An 82-year-old man with An 82-year-old man with hypertension, diabetes, mild CHF, hypertension, diabetes, mild CHF, and a previous ischemic stroke has and a previous ischemic stroke has permanent atrial fibrillation.permanent atrial fibrillation.

► He has been on warfarin for about 5 He has been on warfarin for about 5 years and his INR has remained years and his INR has remained constant between 2.3 and 2.7.constant between 2.3 and 2.7.

► He has a HAS-BLED score of 3.He has a HAS-BLED score of 3.


Which regimen would you continue or switch Which regimen would you continue or switch to for prophylaxis against stroke?to for prophylaxis against stroke?

1)1) Continue current therapy with warfarinContinue current therapy with warfarin

2)2) Aspirin 81 mg + clopidogrel 75 mg dailyAspirin 81 mg + clopidogrel 75 mg daily





A 75-year-old man with a CHADSA 75-year-old man with a CHADS2 2 of 3 has of 3 has been taking dabigatran 150 mg for SPAF. His been taking dabigatran 150 mg for SPAF. His estimated GFR was 55 estimated GFR was 55 mL/min 6 months ago 6 months ago and is now 40 and is now 40 mL/min. .

I would now:I would now:1)1) Continue to monitor patientContinue to monitor patient

2)2) Switch patient to 75 mg dabigatran twice Switch patient to 75 mg dabigatran twice per dayper day

3)3) Switch patient to warfarinSwitch patient to warfarin

4)4) Switch patient to rivaroxabanSwitch patient to rivaroxaban

5)5) Start ASA and clopidogrelStart ASA and clopidogrel


CLINICAL CASES. Atrial Fibrillation Case Study #2 ► An 81-year-old white female with a history of chronic, non-valvular AF, a history of a previous ischemic.

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