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Mrs DP, 70 years old, Caucasian.

Presented to the emergency department with a 2hr history of sudden onset SOB, chest discomfort and palpitations

NKDA

Does not drink or smoke

Past Medical History

HTN (diagnosed in 2006, well controlled)

⁰DM, ⁰Angina, ⁰Gord, ⁰Emboli, ⁰Malignancy, ⁰AF, ⁰Asthma

Drug History

Amlodipine 5mg od

Indapamide 2.5mg od

LT

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1. STEMI/NSTEMI - suggested by her alarming chest pain and needs to be ruled out. If her pain has lasted more than 30 minutes or has not subsided with rest, this is more likely. Need troponin levels and an ECG.

2. Angina - suggested by her alarming chest pain and her history of hypertension. If her pain has subsided with rest, then this is more likely. Need her troponin levels and an ECG.

3. Atrial Fibrillation - suggested by her breathlessness, chest pain and palpitations. May have a precipitating cause, such as thyrotoxicosis, MI or infection. Need an ECG.

4. Pulmonary Emboli - suggested by her breathlessness and chest pain. Need to know if she has any thrombotic risk factors (recent surgery, malignancy, AF, etc.). May see signs of DVT or respiratory abnormalities on examination.

5. Anaphylaxis - suggested by sudden breathlessness and possibly by the fact she was in her garden at the time - possible insect sting. Need to know allergies and if there is any oedema.

6. Pneumothorax - suggested by alarming chest pain and sudden breathlessness. Will have abnormal respiratory examination and possibly low BP.

7. Oesophageal spasm - suggested by her alarming chest pain. Can be differentiated from MI by troponin levels and ECG (which will be normal). Need to know if she has any risk factors (change in diet, NSAID use).

References:
NICE: Chest pain overview [Internet].; [cited 20th November 2017]. Available from: https://pathways.nice.org.uk/pathways/chest-pain.
BMJ. Assessment of chest pain [Internet].; [cited 20th November 2017]. Availble from: http://bestpractice.bmj.com/topics/en-gb/301

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Atrial Fibrillation:

Personalised Package of Care including:
1. stroke awareness and measures to prevent stroke

2. rate control

3. assessment of symptoms for rhythm control

4. who to contact for advice if needed

5. psychological support if needed

up‑to‑date and comprehensive education and information on:

5.1 cause, effects and possible complications of atrial fibrillation

5.2 management of rate and rhythm control

5.3 anticoagulation

practical advice on anticoagulation in 'Venous thromboembolic diseases' (support networks (for example, cardiovascular charities)

Referral to Specialised Management

Assess Stroke Risk using CHA ₂ DS ₂-VASc stroke risk score

Assess Bleeding Risk using HAS – BLED score

Interventions to prevent stroke

Anti-coagulation:
For Example Apixaban

Prophylaxis of stroke and systemic embolism in non-valvular atrial fibrillation and at least one risk factor (such as previous stroke or transient ischaemic attack, symptomatic heart failure, diabetes mellitus, hypertension, or age 75 years and over

By mouth
5 mg twice daily

Assessing anticoagulation control with Vitamin K Antagonist

Calculate (TTR) at each visit.

exclude measurements taken during the first 6 weeks of treatment

calculate TTR over a maintenance period of at least 6 months.

If poor anticoagulation control cannot be improved, evaluate the risks and benefits

Do not administer Aspirin monotherapy
PS
Source: Nice Guidelines

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Apixaban:

Risk factor for major bleeding

Do not use/Be careful:

- in conditions with significant risk factors for major bleeding, including current or recent gastrointestinal ulceration,

- malignant neoplasms at high risk of bleeding,

- recent brain, spinal or ophthalmic surgery,

- recent intracranial haemorrhage,

- known or suspected oesophageal varices,

- arteriovenous malformations,

- vascular aneurysms

- major intraspinal or intracerebral vascular abnormalities.

Inform patient that it should not be taken with OTC ibuprofen as it increases the risk of bleeding

Common Side Effects:
Anaemia; bruising; haemorrhage; nausea

Monitoring:

Patient should be monitored for signs of bleeding or anaemia (patient is borderline with her Hb so needs careful monitoring); treatment should be stopped if severe bleeding occurs. No routine anticoagulant monitoring required (INR tests are unreliable)

PS

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Patients with new onset AF need long term follow up >
Patient needs 6-12 months follow up which includes an Echo- cardiogram and exercise stress testing.

She is an active lady who does not drink or smoke and eats well so no lifestyle advice needed. Staying fit will help prevent frailty which is important in elderly patients regardless of morbidity.
Note; Caffeine can trigger AF so needs to be explained to patient that it is better avoided.

RM
Source: BMJ best practice online and ABC Geriatrics.

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Chest pain: more dull discomfort rather than pain 5/10

Mild respiratory distress at rest (Respiratory rate 20/min)

Temperature 37.2oC

Pulse 142/min irregularly irregular

BP 139/77mmHg

BMI 22

Bloods

Hb 112 (115-165g/L)

WCC 6.3 (4.0- 11.0 x 10 ⁹/L)

Plt 210 (150-400x 10 ⁹/L)

Na 139 (137-144 mmol/L)

K 4.0 (3.5-4.9 mmol/L)

Ur 4.6 (2.5-7mmol/L)

Cr 72 (60-110 µmol/L)

Mg 0.94 (0.75-1mmol/l)

Serum troponin T 10µg/L (<0.01)

CRP: 5

Blood glucose:6.2

LFTs: normal

INR-1 (<1.2)

ABGs:

PO2  10.1 (11.3-12.6kPa)

PCO2  4.3 (4.7- 6.0kPA)

pH 7.39 (7.35-7.45)

Lactate: 1.1 (0.5-1.6mmol/L)

LT

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Assessment bleeding risk with HASBLED and CHA2DS2-VASc 

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Assessment bleeding risk with HASBLED and CHA2DS2-VASc 

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Patient has a CHA2DS"-VASc score 3 (reasons, hypertension, female/sex and age 64-74yrs) indicating she is at high risk of stroke[1]. Anti-coagulation therapy should be considered and the recommended options for this patient are warfarin, dabigatran 150mg bd, rivaroxaban 20mg od, apixaban 5mg bd or edoxaban 60mg od [1]. Discuss the options for anticoagulation with the patient and base the choice on their clinical features and preferences. When discussing the benefits and risks of anticoagulation, explain that for most people the benefit of anticoagulation outweighs the bleeding risk.
The patient has a HASBLED score 1 (reason, age > 65years) [2] indicating she is at low risk of bleeding and does not require regular clinical review after the initiation of anticoagulation therapy.

KPM

References
| [1]  | NICE, "Atrial Fibrillation Management," August 2014. [Online]. Available: https://www.nice.org.uk/guidance/CG180. [Accessed 19 November 2017].
| [2]  | Keele University, "Decision Support Anticoagulation therapy for the prevention of stroke and systemic embolism in atrial fibrillation," 25 July 2016. [Online]. Available: https://www.anticoagulation-dst.co.uk/profile/create. [Accessed 19 November 2017].

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DIAGNOSIS (> needs positives and negatives based on differentials?)

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DIAGNOSIS (> needs positives and negatives based on differentials?)

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AF (146bpm, irregular QRS complexes and no P waves)

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* stroke is the main risk of AF (but should be managed by the Apixaban)
* an acute myocardial infarction (due to rapid ventricular rate and increased myocardial stress)
* congestive heart failure (due to increased myocardial demands and any other risk factors present like valvular disease which she does not have, neither does she have high cholesterol, minimising risk of atherosclerotic cardiac problems)

RM
Source: BMJ best practice online

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ECG shows irregular QRS complexes and no P waves which could have been precipitated by the previously diagnosed hypertension.
1st line therapy would be a beta-blocker: Atenlol 50mg OD

Patient's blood pressure should be monitored while in hospital as well as another ECG should be performed to ensure beta-blocker is working. If necessary Atenolol can be increased to 100mg OD for improved rate control.

BS

Source: NICE guidance Atrial Fibrillation: management
https://www.nice.org.uk/guidance/cg180/chapter/1-Recommendations#rate-and-rhythm-control-2
NICE CKS Atrial Fibrillation
https://cks.nice.org.uk/atrial-fibrillation#!scenario

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- Amlodipine 5mg OD
- Indapamide 2.5mg OD
- Apixaban 5mg BD
- Atenolol 50mg OD

GP to monitor:
- Bleeding risk and ADRs
- BP
- HR
- Hb levels
in routine 6 monthly appointments.

If necessary, another rate-control drug can be added ie. rate-limiting CCB or Digoxin.

BS

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Long-term AF is associated with reduced life-expectancy.
It is important to monitor any factors that may increase the risk of patients having stroke therefore cholesterol levels need to be monitored and the patient should continue their lifestyle, keeping active and avoiding alcohol and smoking.

BS
Source: EverydayHealth
How to Improve Your Atrial Fibrillation prognosis
https://www.everydayhealth.com/hs/atrial-fibrillation-and-stroke/improve-afib-prognosis/