Transcript Advanced Practice Nursing in Acute and Critical Care

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
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
 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:
1) 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.
2) Because of the patient's risk profile, there should be an
attempt to provide thromboprophylaxis against embolic
stroke.
Atrial Fibrillation Case Study #2
 The cardiologist has determined that this
patient requires antithrombotic management
for stroke prevention.
 At this point you would most likely:
1) Try the patient on warfarin again
2) Try to re-introduce clopidogrel and aspirin
3) Treat the patient with aspirin alone
4) Introduce a non-monitored oral anticoagulant to
the patient's regimen.
Atrial Fibrillation Case Study #3
► 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
 Which regimen would you prescribe for
prophylaxis against thromboembolism?
1. Warfarin (INR 2.0-3.0)
2. Warfarin (INR 1.5-2.0)
3. Aspirin 81 mg daily
4. Aspirin 81 mg + clopidogrel 75 mg daily
5. An oral Factor Xa or direct thrombin inhibitor
Atrial Fibrillation Case Study
Anticoagulation 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…”
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:
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
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?
1) Warfarin
2) Dabigatran
3) Apixaban
4) Rivaroxaban
5) All of the above
Atrial Fibrillation
Knowledge Assessment Question
The major potential benefits of the new nonmonitored oral anticoagulants include:
1) Rapid therapeutic anticoagulant effect
2) Greater safety with regards to intracranial hemorrhage
3) Proven reversal agent
4) All of the above
5) Both 1 and 2
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:
1) Dabigatran 150 mg twice daily
2) Dabigatran 75 mg twice daily
3) Warfarin titrated to goal INR 2-3
4) Rivaroxaban 20 mg once daily
5) Rivaroxaban 15 mg once daily
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.
Atrial Fibrillation Case Study #7
 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
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?
1) Dabigatran 150 mg twice daily
2) Dabigatran 75 mg twice daily
3) Rivaroxaban 20 mg once daily
4) Rivaroxaban 15 mg once daily
5) Both 1 and 4
Atrial Fibrillation Case Study #8
 What would her options be if her creatinine
clearance was stable at 25 mL/min?
1) Dabigatran 75 mg twice daily
2) Rivaroxaban 15 mg once daily
3) Only warfarin can be used in patients with creatinine
clearance < 30 mL/min
4) Both 1 and 2
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.
Atrial Fibrillation Case Study #9
 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
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?
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
Atrial Fibrillation Case Study #10
 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
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:
1) No antithrombotic therapy
2) Discontinue warfarin and start aspirin
3) Discontinue warfarin and start dabigatran
4) Discontinue warfarin and start rivaroxaban
5) Discontinue warfarin and start apixaban
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?
1) Aspirin
2) Aspirin and clopidogrel
3) Dabigatran
4) Apixaban
5) Rivaroxaban
Atrial Fibrillation Case Study #13
 A 68-year-old man with a mechanical mitral valve
develops AF.
 The best anticoagulant option for him is:
1) Warfarin
2) Dabigatran
3) Apixaban
4) Rivaroxaban
5) Aspirin
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?
1) He no longer requires anticoagulation now that he is in
sinus rhythm
2) Patient should be on both aspirin and an anticoagulant
3) Patient should be on an anticoagulant alone
4) Aspirin and clopidogrel together is as effective as
anticoagulation in these patients
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:
1) Try the patient on warfarin again
2) Treat the patient with aspirin alone
3) Introduce the non-monitored oral anticoagulant,
apixaban, into the patient's regimen
4) Introduce dabigatran into the patient’s regimen
5) Introduce rivaroxaban into the patient’s regimen
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.
Atrial Fibrillation Case Study #15
 At this point you would:
1) Continue to try to stabilize his INR on warfarin
2) Change to aspirin alone
3) Introduce the non-monitored oral anticoagulant rivaroxaban
into the patient's regimen
4) Introduce the non-monitored oral anticoagulant apixaban
into the patient's regimen
5) Introduce the non-monitored oral anticoagulant dabigatran
into the patient's regimen
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.
Atrial Fibrillation Case Study #17
 Which regimen would you initiate for prophylaxis
against stroke?
1) Warfarin (INR 2.0-3.0)
2) Aspirin 81 mg + clopidogrel 75 mg daily
3) Rivaroxaban
4) Apixaban
5) Dabigatran
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.
Atrial Fibrillation Case Study #18
 Which regimen would you continue or switch to for
prophylaxis against stroke?
1) Continue current therapy with warfarin
2) Aspirin 81 mg + clopidogrel 75 mg daily
3) Rivaroxaban
4) Apixaban
5) Dabigatran
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:
1) Continue to monitor patient
2) Switch patient to 75 mg dabigatran twice per day
3) Switch patient to warfarin
4) Switch patient to rivaroxaban
5) Start ASA and clopidogrel