What is the recommended workup and management for a 75-year-old patient with atrial fibrillation (AFib) and hypertension (HTN)?

Comprehensive Workup and Management for a 75-Year-Old with Atrial Fibrillation and Hypertension

A 75-year-old patient with atrial fibrillation and hypertension requires immediate oral anticoagulation, blood pressure optimization with ACE inhibitors or ARBs, and a comprehensive risk factor management approach to reduce mortality and improve quality of life.

Initial Diagnostic Workup

1. ECG Documentation

   • 12-lead ECG to confirm AF diagnosis 1
   • Document AF pattern (paroxysmal, persistent, or permanent)

2. Stroke Risk Assessment

   • Calculate CHA₂DS₂-VASc score (minimum 3 points: age ≥75 [2 points] + hypertension [1 point]) 2
   • This score indicates high stroke risk (3.2-5.9% annual risk) 2

3. Bleeding Risk Assessment

   • Evaluate using HAS-BLED score 2
   • Identify modifiable bleeding risk factors (uncontrolled hypertension, medications, alcohol use)

4. Cardiac Structure and Function

   • Echocardiogram to assess:
     • Left atrial size and function
     • Left ventricular function (systolic and diastolic)
     • Valvular disease
     • Left ventricular hypertrophy from hypertension

5. Hypertension Evaluation

   • 24-hour ambulatory blood pressure monitoring
   • Target organ damage assessment (retinopathy, nephropathy)
   • Secondary hypertension screening if clinically indicated

Management Strategy

1. Stroke Prevention (Highest Priority)

• Oral Anticoagulation
  • Direct oral anticoagulants (DOACs) are preferred over warfarin due to lower intracranial hemorrhage risk and no need for routine monitoring 2
  • Dose adjustment considerations for age ≥75:
    • Apixaban: 5 mg twice daily (reduce to 2.5 mg twice daily if two of: age ≥80, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) 3
    • Rivaroxaban: 20 mg daily with evening meal (reduce to 15 mg daily if CrCl 30-50 mL/min) 4
  • Warfarin (INR 2.0-3.0) if DOACs contraindicated or if patient has mechanical valve

2. Blood Pressure Management

• Target BP: <130/80 mmHg
• First-line therapy: ACE inhibitors or ARBs 1
  • These agents reduce AF recurrence and progression while providing cardiovascular protection
  • Consider combination with diuretic if needed for BP control
• Regular BP monitoring: Home BP monitoring with AF detection capability

3. Rate vs. Rhythm Control

• Rate control strategy is appropriate for most 75-year-olds with permanent AF 1

  • First-line agents: Beta-blockers, diltiazem, verapamil, or digoxin
  • Target resting heart rate <110 bpm
  • Avoid combination of beta-blockers with diltiazem/verapamil without specialist supervision

• Consider rhythm control if:

  • Patient is highly symptomatic despite rate control
  • Recent onset AF (<12 months) 1
  • Options include:
    • Cardioversion (electrical or pharmacological)
    • Antiarrhythmic drugs (with caution in elderly)
    • Catheter ablation in selected cases

4. Comprehensive Risk Factor Management

• Weight management: Target BMI 20-25 kg/m² 1
• Physical activity: 150-300 min/week of moderate intensity exercise 1
• Alcohol reduction: Limit to ≤3 standard drinks per week 1
• Sleep apnea: Screen and treat if present 1
• Diabetes management: Consider SGLT2 inhibitors if diabetic 1

Follow-up and Monitoring

1. Regular ECG monitoring to assess rate control and rhythm
2. Blood pressure monitoring at each visit and home monitoring
3. Renal function and electrolytes monitoring (especially if on ACE/ARB)
4. Anticoagulation monitoring:
   • If on warfarin: Regular INR checks
   • If on DOAC: Annual renal function assessment
5. Symptom assessment using standardized tools

Important Considerations and Pitfalls

• Avoid aspirin monotherapy for stroke prevention in AF as it is ineffective 1
• Avoid combining antiplatelet therapy with anticoagulation unless specifically indicated (recent ACS or stent), as this significantly increases bleeding risk 1
• Don't withhold anticoagulation based on age alone - the benefit of stroke prevention outweighs bleeding risk even in elderly patients 2
• Beware of drug interactions with anticoagulants, particularly with DOACs
• Don't rely solely on symptom-based questionnaires when screening for obstructive sleep apnea 1

By implementing this comprehensive management approach focusing on anticoagulation, blood pressure control, and risk factor management, you can significantly reduce morbidity and mortality while improving quality of life in this 75-year-old patient with AF and hypertension.