What is the next step for a 93-year-old male with a history of atherosclerosis, aortic and mitral valve disease, and a pacemaker, who has chronic heart failure and atrial fibrillation (A. Fib), and is experiencing increased left foot swelling while on coumadin (warfarin)?

From the Guidelines

The next step for this 93-year-old male with new left foot swelling should be an urgent medical evaluation to determine the cause of the edema. The physician should assess whether this represents worsening heart failure, a possible deep vein thrombosis (DVT), or medication side effect. The evaluation should include:

• A physical examination focusing on bilateral lower extremities
• Vital signs including weight
• Laboratory tests including BNP (brain natriuretic peptide), renal function, and INR to check warfarin therapeutic levels
• A duplex ultrasound of the left lower extremity should be performed to rule out DVT, especially given the patient's anticoagulation with warfarin 1. If heart failure exacerbation is confirmed, the physician may increase the patient's diuretic dose temporarily or add a second diuretic like metolazone 2.5-5mg daily alongside his current regimen. Fluid and sodium restriction (less than 2g sodium daily) should be reinforced. The patient should elevate his legs when sitting and monitor daily weights. This approach is critical because unilateral swelling in an elderly patient with atrial fibrillation raises concern for thromboembolism despite anticoagulation, particularly if the INR is subtherapeutic. Additionally, worsening heart failure can manifest as peripheral edema and requires prompt intervention to prevent further decompensation in this high-risk elderly patient with multiple cardiac comorbidities 1.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

2.1 Individualized Dosing The dosage and administration of COUMADIN must be individualized for each patient according to the patient’s INR response to the drug. Adjust the dose based on the patient’s INR and the condition being treated Consult the latest evidence-based clinical practice guidelines from the American College of Chest Physicians (ACCP) to assist in the determination of the duration and intensity of anticoagulation with COUMADIN

The next step for a 93-year-old male with a history of atherosclerosis, aortic and mitral valve disease, and a pacemaker, who has chronic heart failure and atrial fibrillation (A. Fib), and is experiencing increased left foot swelling while on coumadin (warfarin) is to:

• Assess the patient's current condition, including the severity of the left foot swelling and any potential causes.
• Evaluate the patient's INR levels to ensure they are within the target range (2.0-3.0) for atrial fibrillation.
• Consider consulting the latest evidence-based clinical practice guidelines from the American College of Chest Physicians (ACCP) to determine the best course of action.
• Adjust the coumadin dose as needed based on the patient's INR response and condition being treated.
• Monitor the patient closely for any signs of bleeding or other complications. 2

From the Research

Patient Assessment

The patient is a 93-year-old male with a history of atherosclerosis, aortic and mitral valve disease, and a pacemaker, who has chronic heart failure and atrial fibrillation (A. Fib), and is experiencing increased left foot swelling while on coumadin (warfarin) 3, 4, 5, 6, 7.

Key Considerations

• The patient's symptoms of left foot swelling could be indicative of worsening heart failure, as edema is a common symptom of fluid overload in heart failure patients 3, 4.
• The patient's history of atrial fibrillation and heart failure with reduced ejection fraction increases the risk of stroke, requiring oral anticoagulation 5, 6, 7.
• The patient's current medication regimen, including coumadin, should be evaluated to ensure optimal management of atrial fibrillation and heart failure 5, 6, 7.

Next Steps

• Perform a physical examination to assess for signs of fluid overload, such as pulmonary rales, an S3 heart sound, or extremity edema 3.
• Obtain a complete blood count, basic metabolic profile, liver function tests, troponin, brain natriuretic peptide, and a chest radiograph to evaluate the patient's cardiac function and identify potential causes of worsening heart failure 3.
• Consider using point-of-care ultrasound to assess for B-lines, cardiac function, and inferior vena cava size, which can facilitate the diagnosis of heart failure 3.
• Evaluate the patient's current medication regimen and consider adjustments to optimize management of atrial fibrillation and heart failure, including the potential use of catheter ablation for rhythm control 7.
• Assess the patient's renal function and consider the potential need for adjustments to anticoagulation therapy 6.