What is the role of Farxiga (dapagliflozin) and digoxin in managing persistent atrial fibrillation (AFib) in a post-cabbage surgery patient with Barrett's esophagus, who is on pantoprazole, Eliquis (apixaban), and metoprolol?

Management of Persistent AFib in Post-CABG Patient with Barrett's Esophagus

Beta-blockers should be the primary rate control agent for this post-CABG patient with persistent AFib, with digoxin as an appropriate adjunctive therapy, while Farxiga (dapagliflozin) has no direct role in AFib management but may provide cardiovascular benefits if the patient has heart failure or chronic kidney disease. 1

Rate Control Strategy for Post-CABG AFib

Primary Rate Control Options

• Beta-blockers (such as metoprolol) are recommended as first-line therapy for rate control in patients with persistent AFib following cardiac surgery 1
• Continuing metoprolol is appropriate for this patient as it is specifically recommended for post-operative AFib management 1, 2
• Beta-blockers are particularly beneficial in post-CABG patients, with strong evidence (Class I, Level A) supporting their use to treat post-operative AFib 1

Role of Digoxin

• Digoxin is an appropriate adjunctive therapy to beta-blockers for rate control in AFib, especially for controlling heart rate both at rest and during exercise 1
• The combination of digoxin and a beta-blocker is reasonable (Class IIa recommendation) to achieve optimal rate control, with dosage modulated to avoid bradycardia 1
• Digoxin is particularly useful in patients with heart failure and left ventricular dysfunction, though it should not be used as the sole agent for rate control in paroxysmal AFib 1

Medication Interactions and Monitoring

• When using digoxin, regular monitoring of serum electrolytes and renal function is essential 3
• Pantoprazole (which the patient is currently taking) may interact with digoxin, potentially affecting absorption, requiring careful monitoring 3
• Digoxin has a narrow therapeutic window, and dose adjustments may be necessary based on renal function, especially in post-surgical patients 3

Role of Farxiga (Dapagliflozin) in This Patient

Not Indicated for AFib Management

• Dapagliflozin (Farxiga) is not indicated for the direct management of atrial fibrillation 4
• Current guidelines do not recommend SGLT2 inhibitors for rhythm or rate control in AFib 1

Potential Benefits in Specific Conditions

• If the patient has heart failure, dapagliflozin has shown benefits in reducing hospitalization for heart failure regardless of AFib status 5, 6
• Dapagliflozin has demonstrated cardiovascular benefits in patients with chronic kidney disease, reducing the composite endpoint of CV death or hospitalization for heart failure 4
• Dapagliflozin did not significantly reduce the risk of new-onset AFib in patients with heart failure with reduced ejection fraction 6

Anticoagulation Considerations

Current Anticoagulation

• The patient is appropriately on Eliquis (apixaban), which is recommended for stroke prevention in AFib 1
• Apixaban has demonstrated consistent reduction in stroke, mortality, and major bleeding regardless of AFib type and duration 7

Post-CABG Considerations

• For post-CABG patients with AFib, transitioning from triple therapy to dual therapy (oral anticoagulant plus single antiplatelet) after 1-6 months is recommended, depending on stent type and bleeding risk 8
• Long-term therapy should be oral anticoagulation alone after 12 months 8

Special Considerations for This Patient

Barrett's Esophagus Management

• Continuing pantoprazole is appropriate for gastric protection due to Barrett's esophagus and as prophylaxis while on antithrombotic therapy 8
• There are no specific contraindications to the current medication regimen related to Barrett's esophagus 8

Post-Surgical AFib Management

• Post-CABG AFib may resolve spontaneously, but persistent AFib requires ongoing management 1, 9
• An individualized approach aimed at rate control using beta-blockers with close monitoring is recommended 9
• If rate control remains inadequate despite optimized medical therapy, consideration of atrioventricular node ablation may be warranted in severely symptomatic patients 1

Monitoring and Follow-up

• Regular assessment of heart rate control during both rest and exercise is recommended 1
• A lenient rate control target (resting heart rate <110 bpm) is appropriate, with stricter control if symptoms persist 1
• Periodic evaluation of renal function is essential, especially when using digoxin and considering the potential addition of dapagliflozin 4, 3