1 / 31

CLINICAL CASES

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

shakti
Download Presentation

CLINICAL CASES

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CLINICAL CASES

  2. An 81-year-old white female with a history of chronic, non-valvular AF, a history of a previous ischemic stroke, and a history of mild congestive heart failure has been on a combination of clopidogrel and aspirin therapy because she was found to be intolerant of warfarin. • She is on a proton pump blocker, an ACE inhibitor, a diuretic, and digoxin. • She is admitted to the hospital for a GI bleed, and is found to have a hematocrit of 29 and a hemoglobin of 9.8. The aspirin and clopidogrel are discontinued. Atrial Fibrillation Case Study #2

  3. The patient stabilizes, and the cardiologist is consulted to determine the subsequent course of her antithrombotic treatment. She has a HAS-BLED score of 3. • It is your opinion that: • Because of the documented GI bleed, the patient should not be treated with antithrombotic agents, because the risk of bleeding outweighs the risk of stroke and its complications. • Because of the patient's risk profile, there should be an attempt to provide thromboprophylaxis against embolic stroke. Atrial Fibrillation Case Study #2

  4. The cardiologist has determined that this patient requires antithrombotic management for stroke prevention. • At this point you would most likely: • Try the patient on warfarin again • Try to re-introduce clopidogrel and aspirin • Treat the patient with aspirin alone • Introduce a non-monitored oral anticoagulant to the patient's regimen.   Atrial Fibrillation Case Study #2

  5. An 82-year-old man with hypertension and diabetes has permanent atrial fibrillation. • He has a history of spinal stenosis and walks with a walker and has a history of falls. • He has a CHADS-VASc score of 3, and a HAS—BLED score of 2. • Which regimen would you prescribe for prophylaxis against thromboembolism? Atrial Fibrillation Case Study #3

  6. Atrial Fibrillation Case Study #3 • Which regimen would you prescribe for prophylaxis against thromboembolism? • Warfarin (INR 2.0-3.0) • Warfarin (INR 1.5-2.0) • Aspirin 81 mg daily • Aspirin 81 mg + clopidogrel 75 mg daily • An oral Factor Xa or direct thrombin inhibitor

  7. Atrial Fibrillation Case StudyAnticoagulation in Patients at Risk of Falls “…persons taking warfarin must fall about 295 (535/1.81) times in 1 year for warfarin notto be the optimal therapy…”

  8. Atrial Fibrillation Case Study #4 • 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: • Placement of a drug-eluting stent with plan to continue anticoagulation in addition to 1 year of dual antiplatelet therapy • Placement of a drug-eluting stent with 1 year of dual antiplatelet therapy alone • Placement of a bare metal stent with plan to continue anticoagulation in addition to 1 month of dual antiplatelet therapy • Placement of a bare metal stent with 1 month of dual antiplatelet therapy alone

  9. Atrial Fibrillation Case Study #5 • 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? • Warfarin • Dabigatran • Apixaban • Rivaroxaban • All of the above

  10. Atrial Fibrillation Knowledge Assessment Question • The major potential benefits of the new non-monitored oral anticoagulants include: • Rapid therapeutic anticoagulant effect • Greater safety with regards to intracranial hemorrhage • Proven reversal agent • All of the above • Both 1 and 2

  11. Atrial Fibrillation Case Study #6 • An 82-year-old man with AF has had several admissions over the past 6 months for heart failure complicated by worsening renal function. His creatinine clearance is currently 20 mL/min but frequently fluctuates to 10-15 mL/min. He has a HAS-BLED score of 3. • The best anticoagulant regimen for stroke prevention is: • Dabigatran 150 mg twice daily • Dabigatran 75 mg twice daily • Warfarin titrated to goal INR 2-3 • Rivaroxaban 20 mg once daily • Rivaroxaban 15 mg once daily

  12. Atrial Fibrillation Case Study #7 • 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.

  13. Atrial Fibrillation Case Study #7 • Which of her symptoms could be due to warfarin? • Thinning hair • Cold intolerance • Fatigue • Both 1 and 2 • All of the above

  14. Atrial Fibrillation Case Study #8 • 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? • Dabigatran 150 mg twice daily • Dabigatran 75 mg twice daily • Rivaroxaban 20 mg once daily • Rivaroxaban 15 mg once daily • Both 1 and 4

  15. Atrial Fibrillation Case Study #8 • What would her options be if her creatinine clearance was stable at 25 mL/min? • Dabigatran 75 mg twice daily • Rivaroxaban 15 mg once daily • Only warfarin can be used in patients with creatinine clearance < 30 mL/min • Both 1 and 2

  16. Atrial Fibrillation Case Study #9 • 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.

  17. Atrial Fibrillation Case Study #9 • Which of the following lab tests, if normal, would reassure the team that the patient is not anticoagulated? • INR (international normalized ratio) • aPTT (activated partial thromboplastin time) • PT (prothrombin time) • Bleeding time

  18. Atrial Fibrillation Case Study #10 • 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? • Start dabigatran when his INR < 3 • Start dabigatran when his INR < 2 • Start dabigatran 24 hours after his last dose of warfarin

  19. Atrial Fibrillation Case Study #10 • What if you decided to switch the patient to rivaroxaban? • Start rivaroxaban when his INR < 3 • Start rivaroxaban when his INR < 2 • Start rivaroxaban 24 hours after his last dose of warfarin

  20. Atrial Fibrillation Case Study #11 • A 78-year-old female with AF, systolic heart failure, hypertension, diabetes, and a history of significant GI bleeding has been on warfarin for many years but has had a difficult time controlling her INR with frequent supertherapeutic values despite intensive monitoring and titration of her warfarin dose. Her HAS-BLED score is 3. The best treatment option for her is: • No antithrombotic therapy • Discontinue warfarin and start aspirin • Discontinue warfarin and start dabigatran • Discontinue warfarin and start rivaroxaban • Discontinue warfarin and start apixaban

  21. Atrial Fibrillation Case Study #12 • 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? • Aspirin • Aspirin and clopidogrel • Dabigatran • Apixaban • Rivaroxaban

  22. Atrial Fibrillation Case Study #13 • A 68-year-old man with a mechanical mitral valve develops AF. • The best anticoagulant option for him is: • Warfarin • Dabigatran • Apixaban • Rivaroxaban • Aspirin

  23. Atrial Fibrillation Case Study #14 • A 76-year-old man with heart failure and hypertension undergoes successful catheter ablation for symptomatic AF. • Which of the following is true regarding his anticoagulation management? • He no longer requires anticoagulation now that he is in sinus rhythm • Patient should be on both aspirin and an anticoagulant • Patient should be on an anticoagulant alone • Aspirin and clopidogrel together is as effective as anticoagulation in these patients

  24. Atrial Fibrillation Case Study #14 • The cardiologist has determined that this patient requires antithrombotic management for stroke prevention. At this point you would most likely: • Try the patient on warfarin again • Treat the patient with aspirin alone • Introduce the non-monitored oral anticoagulant, apixaban, into the patient's regimen • Introduce dabigatran into the patient’s regimen • Introduce rivaroxaban into the patient’s regimen

  25. Atrial Fibrillation Case Study #15 • A 75-year-old male with a history of chronic, non-valvular AF, diabetic renal disease, previous history of ischemic stroke, history of mild HF, and controlled hypertension has been on warfarin therapy. The HAS-BLED score is 4. • For the past 6 months, despite repeated visits for monitoring and warfarin dose adjustment, his INR has varied between 1.5 and 4.3. • His estimated GFR is 30 mL/min.

  26. Atrial Fibrillation Case Study #15 • At this point you would: • Continue to try to stabilize his INR on warfarin • Change to aspirin alone • Introduce the non-monitored oral anticoagulant rivaroxaban into the patient's regimen • Introduce the non-monitored oral anticoagulant apixaban into the patient's regimen • Introduce the non-monitored oral anticoagulant dabigatran into the patient's regimen

  27. Atrial Fibrillation Case Study #17 • An 82-year-old man with hypertension, diabetes, mild congestive heart failure, and previous ischemic stroke, is diagnosed with atrial fibrillation. • He has not been taking any anticoagulants.

  28. Atrial Fibrillation Case Study #17 • Which regimen would you initiate for prophylaxis against stroke? • Warfarin (INR 2.0-3.0) • Aspirin 81 mg + clopidogrel 75 mg daily • Rivaroxaban • Apixaban • Dabigatran

  29. Atrial Fibrillation Case Study #18 • An 82-year-old man with hypertension, diabetes, mild CHF, and a previous ischemic stroke has permanent atrial fibrillation. • He has been on warfarin for about 5 years and his INR has remained constant between 2.3 and 2.7. • He has a HAS-BLED score of 3.

  30. Atrial Fibrillation Case Study #18 • Which regimen would you continue or switch to for prophylaxis against stroke? • Continue current therapy with warfarin • Aspirin 81 mg + clopidogrel 75 mg daily • Rivaroxaban • Apixaban • Dabigatran

  31. Atrial Fibrillation Case Study #19 • A 75-year-old man with a CHADS2 of 3 has been taking dabigatran 150 mg for SPAF. His estimated GFR was 55 mL/min 6 months ago and is now 40 mL/min. • I would now: • Continue to monitor patient • Switch patient to 75 mg dabigatran twice per day • Switch patient to warfarin • Switch patient to rivaroxaban • Start ASA and clopidogrel

More Related