What is the optimal management plan for a 92-year-old male patient with atrial fibrillation, first-degree AV block, and mild-moderate aortic stenosis on Eliquis (apixaban)?

Management of 92-Year-Old Male with Atrial Fibrillation, First-Degree AV Block, and Mild-Moderate Aortic Stenosis

Apixaban 5 mg twice daily is appropriate for stroke prevention in this 92-year-old patient with documented atrial fibrillation, but additional rate control therapy with a beta-blocker should be initiated to manage his paroxysmal atrial fibrillation. 1, 2

Anticoagulation Management

The patient is correctly started on apixaban 5 mg twice daily for stroke prevention. This is appropriate based on:

• Advanced age (92 years) which places him at high risk for thromboembolism 1
• Documentation of atrial fibrillation on EKG, even though currently in sinus rhythm (paroxysmal AF) 2
• FDA-approved dosing for apixaban is 5 mg twice daily for most patients 3

Dosing Considerations:

• The standard dose of 5 mg twice daily is appropriate unless the patient meets at least two of the following criteria:
  • Age ≥80 years (patient meets this)
  • Body weight ≤60 kg (not mentioned)
  • Serum creatinine ≥1.5 mg/dL (not mentioned) 3
• If the patient meets two or more of these criteria, the dose should be reduced to 2.5 mg twice daily 3

Rate Control Strategy

Despite being in sinus rhythm currently, the patient has documented paroxysmal atrial fibrillation and should receive rate control therapy:

• First-line options:

  • Beta-blockers (metoprolol, carvedilol) are recommended for rate control in patients with AF 1, 2
  • Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are alternatives if beta-blockers are contraindicated 1

• Special considerations:

  • Given the reduced LVEF (45-50%), a beta-blocker would be preferred over calcium channel blockers 2
  • Digoxin should not be used as the sole agent for rate control in paroxysmal AF 1
  • Rate control should target heart rate <110 bpm at rest 2

Management of Aortic Stenosis

The patient has mild-moderate aortic stenosis which requires monitoring but not immediate intervention:

• Regular echocardiographic follow-up every 1-2 years is recommended to monitor progression 4
• The presence of AF in patients with aortic stenosis is associated with worse outcomes, even after adjustment for other predictors (HR 1.56,95% CI 1.33-1.84) 4
• Recent research indicates that AF is a strong predictor of mortality in patients with severe AS, even in those with minimal symptoms 4
• Careful monitoring for symptom development is essential as AVR may be beneficial even in patients with AF and minimal symptoms if AS progresses to severe 4

Cardiac Function Management

Given the patient's cardiac findings:

• Fixed defects in the apex with severe wall motion abnormalities
• Mildly reduced LVEF (45-50%)
• Grade 2 diastolic dysfunction
• Mildly dilated left/right atrium
• Mild-moderate aortic stenosis

The following additional measures are recommended:

• Initiate guideline-directed medical therapy for reduced LVEF:

  • ACE inhibitor or ARB
  • Beta-blocker (which will also serve for AF rate control)
  • Consider mineralocorticoid receptor antagonist if symptoms persist

• Monitor for heart failure symptoms given the reduced LVEF and diastolic dysfunction

Follow-up Recommendations

1. Regular ECG monitoring to assess for recurrence of atrial fibrillation
2. Echocardiographic follow-up every 1-2 years to monitor aortic stenosis progression
3. Regular assessment of rate control adequacy, both at rest and with activity 1
4. Monitor for bleeding complications from anticoagulation
5. Assess for symptoms of heart failure or aortic stenosis progression

Common Pitfalls to Avoid

1. Inadequate anticoagulation: Avoid interrupting anticoagulation without appropriate bridging therapy
2. Attributing symptoms to AF alone: In patients with both AF and aortic stenosis, symptoms may be incorrectly attributed to AF rather than progressive AS 5
3. Overtreatment with rate control: Excessive rate control can lead to symptomatic bradycardia, especially with first-degree AV block
4. Neglecting progression of aortic stenosis: Regular monitoring is essential as AS progression may require intervention even with minimal symptoms in patients with AF 4