What is the optimal discharge plan for a 61-year-old female patient with A-fib and RVR, with a CHADS2 VASc score of 1, and a history of hypothyroidism?

Optimal Discharge Plan for a 61-Year-Old Female with A-fib and RVR

For a 61-year-old female with atrial fibrillation, a CHA₂DS₂-VASc score of 1, and hypothyroidism, the optimal discharge plan should include anticoagulation with Eliquis (apixaban) and continuation of Lopressor for rate control.

Stroke Risk Assessment and Anticoagulation

The patient's CHA₂DS₂-VASc score is 1 (female sex), which places her at an intermediate risk for stroke. According to current guidelines:

• For patients with a CHA₂DS₂-VASc score of 1, the annual stroke risk is approximately 1.3-1.5% 1, 2
• The 2014 AHA/ACC/HRS guidelines state that for patients with nonvalvular AF and a CHA₂DS₂-VASc score of 1, "no antithrombotic therapy or treatment with an oral anticoagulant or aspirin may be considered" (Class IIb recommendation) 1
• More recent evidence suggests that patients with a CHA₂DS₂-VASc score of 1 may benefit from oral anticoagulation, particularly with a direct oral anticoagulant (DOAC) 2, 3

The cardiologist's recommendation to start Eliquis (apixaban) is appropriate based on:

1. The annual stroke risk of 1.61% in patients with CHA₂DS₂-VASc score of 1 meets the threshold for using novel oral anticoagulants (0.9%) 2
2. Apixaban has demonstrated superior efficacy compared to warfarin in reducing stroke and systemic embolism with less major bleeding 4
3. The patient's recent episode of symptomatic AF with RVR increases her risk profile

Rate Control Strategy

• Continuing Lopressor (metoprolol) for AV nodal blockade is appropriate for rate control
• Beta-blockers are first-line agents for rate control in patients with AF
• The patient has already demonstrated good response to this medication

Monitoring Thyroid Function

• Given the patient's history of hypothyroidism, it's important to ensure adequate thyroid replacement therapy
• The patient's TSH of 0.58 is within normal range but should be monitored regularly
• Thyroid dysfunction can trigger or exacerbate atrial fibrillation 5

Follow-up Plan

• The planned cardiology follow-up is essential for ongoing management
• Regular monitoring of:
  • Heart rhythm and rate
  • Symptoms of AF recurrence
  • Effectiveness of rate control
  • Renal function (for DOAC dosing)
  • Thyroid function

Potential Pitfalls and Considerations

1. Bleeding risk assessment: Although not explicitly mentioned, the patient's bleeding risk should be assessed using the HAS-BLED score. Modifiable bleeding risk factors should be addressed 5

2. Medication interactions: The patient is on phentermine, which can potentially increase heart rate and blood pressure. This medication should be reevaluated given her recent AF episode 1

3. Renal function monitoring: Apixaban dosing depends on renal function, age, and weight. Regular monitoring of renal function is necessary 4

4. Rhythm vs. rate control strategy: While the current plan focuses on rate control, a rhythm control strategy might be considered in the future if the patient remains symptomatic despite adequate rate control

5. Patient education: The patient should be educated about:

   • Signs and symptoms of AF recurrence
   • Importance of medication adherence
   • When to seek medical attention
   • Bleeding precautions while on anticoagulation

In summary, the optimal discharge plan for this 61-year-old female with AF, CHA₂DS₂-VASc score of 1, and hypothyroidism should include anticoagulation with apixaban, continuation of metoprolol for rate control, close monitoring of thyroid function, and appropriate follow-up with cardiology.