PHC 550

CASE-BASED LEARNING 1

CASE 3
ATRIAL FIBRILLATION
GROUP
D2
 GROUP
MEMBERS
N
NAME STUDENT ID
O
1 NURFARHANA BINTI FAZLISHA 2017443368

2 SITI AMALIA BINTI MOHD AZAM 2017421298

3 SITI NORBAYA BINTI ABDUL RAHIM 2017421008

4 SITI NORFITRIAH BINTI SALLEH 2017443432

WAN ATIQAH BINTI WAN MOHD
5 2017443366
AZMI
 CASE
DOA
PRESENTATION
: 5 December 2014 DOD : 8 December 2014

Patient History of present illness

• Name : TCH • having palpitation, with worsening

• Age : 60 years shortness of breath while having his dinner
old at 6 pm.
• Race : Chinese • he has been having central chest pain but
• Gender : Male brief episode for the past 5 days
• NKDA Vital signs
Chief complaints
• BP : 142/93
• PR : 150 bpm- irregularly irregular
• Palpitation with shortness
• SpO2 : 96% on air
of breath
• T : 37 ˚C
• Central chest pain
• Normal renal profile (RP), lipid profile
(LP)
Background History
• NSTEMI Social history
• Underlying hypertension Categorized as
• Dyslipidaemia Ejection fraction • Smoking for more than 30 years a heavy smoker
• HF EF <32%. level is < 32%, (10 sticks /day, 15 pack/year) since he smokes
hence, he has > 30 years
heart failure • Non-alcoholic
reduced ejection • Not working since 10 years ago
fraction (HFrEF)
• Married with 6 children
Old medications
• T. Aspirin 150mg OD
• T. Clopidogrel 75mg OD
• s/l GTN 1/1 PRN
IMP/impression/diagnosis:
• T. Simvastatin 40mg ON
• T. Perindopril 6mg OD
Paroxysmal atrial fibrillation
• T. Isordil 10mg TDS
Unstable Angina (UA)- no ECG
• T. Vasteral 20mg TDS.
changes, normal cardiac biomarkers
QUESTION
S
 1. How many types of AF are
there?

First diagnosed AF not diagnosed before, irrespective of its duration or the

AF presence/severity of AF-related symptoms.

Paroxysmal AF that terminates spontaneously or with intervention within 7

AF days of onset.

Persistent AF AF that is continuously sustained beyond 7 days, including

episodes that are terminated by cardioversion (drugs or direct
current cardioversion) after 7 days or more.
Long-standing Continuous AF of ˃ 12 months’ duration when decided to adopt a
Persistent AF rhythm control strategy.

AF that is accepted by the patient and physician, no further

Permanent AF attempt to restore/maintain sinus rhythm will be undertaken.
 2. What are the clinical presentations
showing that the patient has AF?

• Palpitation, with worsening shortness of breath

• Central chest pain
• Vital signs:
• BP : 142/93 mmHg (stage 1 hypertension)
• PR : 150 bpm- irregularly irregular (tachycardia)
• SpO2 : 96% on air (normal people: 99 – 100%)
3. What could be the risk factor of developing
AF in this patient?

Ageing (60 years old)

Male Sex

Comorbidities- Hypertension, Heart failure,

& Dyslipidaemia

Lifestyle – smoking > 30 years, physical

inactivity (not working since 10 years ago)
4. What are the goal of therapy in this
patient?

Maintenance of sinus rhythm

Heart rate control during AF

Prevention of stroke

Prevent blood clotting

 5. How should the patient be managed in
ward?
CHA2DS2-VASc SCORE TO STRATIFY STROKE RISK HAS-BLED SCORE TO STRATIFY BLEEDING RISK

• CHA2DS2-VASc score
is 3 (greater than 2)
• HAS-BLED score is
1(low risk of bleeding)

ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery
(EACTS)
 5. How should the patient be managed in
ward?
Medication to be added:
1) VKA (Warfarin)
• Class : Vitamin K antagonist • Dose :
• Initial treatment : 5 mg PO OD (achieved
• MOA: INR > 2 in 4-5 days)
• Inhibit vitamin K-dependent synthesis
• Thus, inhibiting clotting factor II, VII, IX, • INR monitoring:
and X • Check baseline INR prior to start warfarin
• Check INR daily until achieve therapeutic
• Indication : Prevention of stroke goal for 2 consecutive days
• CHA2DDS2-VASc for stroke risk is 3 (OAC • Check INR 2-3 times weekly
is recommended)
• HAS-BLED for bleeding risk is 1 (low risk of • Target INR:
bleeding • 2.0 – 3.0
Medication to be added:
2) β-blocker (IV Esmolol)
• Indication : Rate control therapy to
manage symptoms
• Recommendation :
• Start smallest dose β-blocker.
• Assess patient LVEF by performing
echocardiogram.
• If LVEF severely reduced, stop β-
blocker and change to IV Amiodarone.
• If not, continue β-blocker.
• Dose IV Esmolol
• 50 - 200 mcg/kg/min Retrieved from ESC Guidelines

• Dose IV Amiodarone:
• 5 mg/kg infuse over 20 min
• Up to a maximum of 1.2 g in 24 hours
Medication to be changed:
 1) Simvastatin Atorvastatin
• Indication : For dyslipidaemia
management and cardiovascular disease
(CVD) risk prevention
• Dose :
• Atorvastatin 80 mg ON
• Monitoring:
• Monitor LDL-C level (targeted LDL-C:
1.8 mmol/L @ at least 50% reduction)
• Lipid re-test about 1 – 3 months
Medication to be continued:

Old Medication Rationale/Comment

T. Aspirin 150mg OD Patient had a history of NSTEMI and he currently
T. Clopidogrel 75mg OD show UA

s/l GTN 1/1 PRN For chest pain. Take only when necessary
T. Perindopril 6mg OD Continue to control hypertension
T. Isordil 10mg TDS For angina pectoris

T. Vasteral 20mg TDS For angina pectoris

Patient progress
5/12/2014
ECG 4pm fast AF rate 128
Repeated at 720pm: still in fast AF
 6. What else should you give to control
patient’s heart rate?

 According to ESC Guideline 2020,

patient with LVEF <40% should be
given smallest dose of beta-blocker
for the rate control
 Others:
- digoxin, amiodarone, diltiazem,
verapamil
 In patients with HFrEF, IV diltiazem
and verapamil (non-DHP CCB)
should be avoided
 Combination of β-blocker and CCB
or CBB and digoxin often necessary
to achieve adequate rate control

Retrieved from ESC Guidelines

 7. Should the patient be discharged with oral
anticoagulants? If so, what are the counselling
points that should be covered in this patient?

Initial treatment recommended : Counselling point :

Warfarin 5 mg PO OD
(administered in the ward)
Check INR 2-3 times weekly (range:
2.0 – 3.0)
Maintenance dose: Warfarin 3 mg
PO OD
 should be taken on an empty stomach at the same time every
day (usually at 6pm).
 avoid alcohol intake and reduce St. John’s Wort because
these can reduce the effectiveness of warfarin
 Stop smoking
 reduce the intake of foods with rich in vitamin K such as
green leafy vegetables, liver, broccoli and brussels sprouts
 avoid cranberry juice cause it may increase INR and risk of
bleeding
 Contact the doctor if there is unusual bleedings or
experiencing difficulty in breathing
 8. This patient has a history of dyslipidemia, discuss on
the current management of dyslipidemia that he is
currently on, is it appropriate and how long should the
patient be on statin?

• Dyslipidaemia
= Abnormal level of lipids in the blood
- Risk factor of cardiovascular disease.
- Statin (HMG-CoA reductase inhibitor)
- Block the cholesterol synthesis at its rate limiting
step and reduce LDL levels, lower the
cholesterol level and eventually reduce risk of
CVD.
 An intensive lipid-lowering
statin regimen provides
greater protection against
death or major
cardiovascular events than
does a standard regimen in
patient with acute coronary
syndrome (Cannon et
al,2004).

Retrieved from MOH, Clinical Practice Guidelines: Management of Dyslipidaemia, 2017 (5 th Edition)
 Continue…

Current medication

Recommendation

Retrieved from MOH, Clinical Practice Guidelines: Management of Dyslipidaemia, 2017 (5 th Edition)
 Continue…
• If no contraindication – should be started immediately
• Continue indefinitely for lifelong benefits.

• Retest lipid level after about 1 – 3 months

• Target LDL-C: <1.8 mmol/L or reduction at least 50 %
References:

• Camm AJ, Savelieva I, Lip GYH. Rate control in the medical management of atrial fibrillation. In:
Heart [Internet]. BMJ Publishing Group; 2007 [cited 2020 Nov 17]. p. 35–8. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1861356/
• Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Belder R, Joyal SV, Hill KA, Pfeffer
MA, Skene AM. Intensive versus Moderate Lipid Lowering with Statins after Acute Coronary
Syndromes. N Engl J Med. 2004;350:1495–1504.
• Ejection Fraction Heart Failure Measurement | American Heart Association. Available at:
https://www.heart.org/en/health-topics/heart-failure/diagnosing-heart-failure/ejection-fraction-heart-
failure-measurement.
• Formulari Ubat KKM (FUKKM) | Program Perkhidmatan Farmasi. (n.d.). Retrieved November 17,
2020, from https://www.pharmacy.gov.my/v2/ms/apps/fukkm?
generic=esmolol&category=&indications=
• Hindricks, G., Potpara, T., Dagres, N., Arbelo, E., Bax, J. J., Blomström-Lundqvist, C., Boriani, G.,
Castella, M., Dan, G.-A., Dilaveris, P. E., Fauchier, L., Filippatos, G., Kalman, J. M., La Meir, M.,
Lane, D. A., Lebeau, J.-P., Lettino, M., Lip, G. Y. H., Pinto, F. J., … Watkins, C. L. (2020). 2020
ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration
with the European Association of Cardio-Thoracic Surgery (EACTS). European Heart Journal.
https://doi.org/10.1093/eurheartj/ehaa612
• Lee, Y. H. et al. (2011) ‘Cumulative smoking exposure, duration of smoking cessation, and
peripheral arterial disease in middle-aged and older Korean men’, BMC Public Health. BioMed
• MOH, Clinical Practice Guidelines: Management of Dyslipidaemia, 2017 (5 th Edition)
• MIMS Malaysia Online. Retrieved from
https://www.mims.com/malaysia/drug/info/warfarin?mtype=generic
• Prystowsky, E. N., Padanilam, B. J., & Fogel, R. I. (2015). Treatment of atrial fibrillation. JAMA -
Journal of the American Medical Association, 314(3), 278–288.
https://doi.org/10.1001/jama.2015.7505
• Wasmer, K., Eckardt, L., & Breithardt, G. (2017). Predisposing factors for atrial fibrillation in the
elderly. Journal of Geriatric Cardiology, 14(3), 179–184.
https://doi.org/10.11909/j.issn.1671-5411.2017.03.010
THANK
YOU