Question

D.G. is a 74-year-old woman who arrives at the emergency room complaining of shortness of breath, palpitations (for 2 days), and lower extremity edema. Her medical history includes diabetes mellitus, hypertension, heart failure with reduced ejection fraction, and osteoarthritis. She had a left heart catheterization and coronary angiography last year and has no significant coronary artery disease. She has a biventricular pacemaker/implantable defibrillator for heart failure symptom treatment and sudden cardiac death prevention. The patient’s current medications are losartan 100 mg/d, metoprolol succinate 50 mg/d, metformin 500 mg twice daily, spironolactone 25 mg/d, furosemide 40 mg/d, and naproxen 500 mg twice daily. Vital signs are as follows: blood pressure of 140/80 mm Hg, respiratory rate of 30 bpm, and heart rate of 120 bpm. ECG shows atrial fibrillation with a rapid ventricular response. Echocardiography reveals a moderately dilated left atrium, left ventricular systolic ejection fraction of 35% (unchanged), chronic kidney disease (baseline serum creatinine 1.01 mg/dL), and moderate mitral regurgitation. Pertinent laboratory values include the following: hemoglobin 12 g/dL, hematocrit 36%, platelets 300,000/microliter, and serum creatinine 1.20 mg/dL (estimated creatinine clearance 39 mL/min). Her weight is 60 kg (increased from 55 kg), and height is 5 ft 3 inches. She does not smoke and does not drink alcohol. Dietary habits include one can of Ensure daily, with other meals provided by a social service agency (Meals on Wheels). Social concerns include the fact she lives alone, but a son visits every 1 to 2 weeks and transports her to physician appointments. She is living on a limited budget. With regard to her medication adherence, her son states that she occasionally forgets to take her afternoon medications, but overall, she is considered to be reasonably adherent with her drug regimens.

Diagnosis: Atrial fibrillation, acute onset

Answer the following questions. Include two references, cited in APA style.

List specific goals of treatment for D.G.

What drug therapy would you prescribe for stroke prevention in atrial fibrillation? Why?

What are the parameters for monitoring success of the anticoagulant therapy?

Discuss specific patient education based on the prescribed therapy.

List one or two adverse reactions for the selected agent that would cause you to change therapy.

What would be the choice for the second-line therapy?

What OTC or alternative medications would be appropriate for D.G.?

What lifestyle changes would you recommend to D.G.?

Describe one or two drug–drug or drug–food interactions for the selected agent.

Answer 1

Specific Goals of treatment for D.G:

• Prevention of Cardiac Death.
• Maintain Fluid and electrolyte balance and adequate urinary elimination.
• Maintain normal body weight.
• Achieve the normal creatinine level.
• Management of secondary disease of diabetes, hypertension, osteoarthritis and prevent further complication.
• Educate about the importance of drug regimens and avoid missing of dose.

Drug therapy for stroke prevention in atrial fibrillation:

Warfarin is the most effective therapy for the prevention of stroke in Af patients. In atrial fibrillation, the chaotic rhythm may form blood clots which may dislodge into the brain and cause stroke. Warfarin prevents the blood clots which decreases the risk of stroke in atrial fibrillation.

Parameters for the anticoagulation therapy:

• Brand of warfarin is important.
• INR should be maintained between 2.0 and 3.0 to minimize the risk of bleeding.
• Maximizes the benefit and minimizes the risk.
• Correct dosage and timely intake of warfarin.

Patient Education on Anticoagulant medications:

• Intake of medication at a correct time every day.
• Wear ID band that indicates the information of anticoagulation intake.
• Use a correct dose of warfarin.
• avoid stopping of warfarin without doctor's advice.
• Inform dentist and other physicians about intake of anticoagulant before undergoing any procedure.
• Avoid vitamin K rich diet.
• Avoid alcohol intake.
• Minimize the risk of injury.
• Avoid intake of other medicines such as antibiotics, anti-inflammatory agents without the physician order.

Adverse Reactions:

• Severe bleeding, bruising.
• Pain, swelling, headache.
• Coughing up of blood.

Second-Line therapy:

Other anticoagulants such as dabigatran, rivaroxaban, aspirin are also effective in the prevention of stroke. Some researchers suggest Ximelagatran 36mg twice daily is more effective than warfarin.

Alternative Medications:

• Aspirin
• Acetaminophen
• Naproxen
• Ibuprofen

Lifestyle changes for D.G;

• Encourage physical activity.
• Change dietary patterns.
• Regular follow-up of care.
• Encourage passive exercises.

Drug Interactions:

• Anticoagulants and vitamin K: While taking anticoagulants, minimize the intake of vitamin K diet. The foods rich in Vitamin K are Broccoli, cabbage, Lentils, Beans, Lettuce, spinach.
• Anticoagulants and vitamins or Herbal supplements: Herbs and vitamins can interact with the anticoagulant. Avoid multivitamin which consists of vitamin K. Fish oil may increase the INR level.