Management of Atrial Fibrillation in a 68-Year-Old Female with Improved Left Ventricular Function
Continued anticoagulation with Eliquis (apixaban) is strongly recommended for this patient with persistent atrial fibrillation and multiple stroke risk factors, despite improvement in left ventricular ejection fraction from 30% to 63% following cardioversion. 1
Current Clinical Status Assessment
- Patient has persistent atrial fibrillation with successful cardioversion, now in sinus rhythm 1
- Significant improvement in LV function from severe dysfunction (EF 30%) to preserved EF (63%) 1
- Reduction in mitral regurgitation from moderate to trivial 1
- Untreated OSA (not using CPAP) which is a risk factor for AF recurrence 1
- Mild airflow obstruction with bronchodilator response on PFTs 1
Anticoagulation Management
- Continue Eliquis (apixaban) as the patient has multiple stroke risk factors (age 68, female, history of heart failure) with CHA₂DS₂-VASc score ≥3 1
- Direct oral anticoagulants (DOACs) like apixaban are preferred over warfarin for eligible patients with non-valvular AF 1
- Anticoagulation should be continued despite successful cardioversion and improved EF, as the risk of thromboembolism persists 1
- Regular monitoring of bleeding risk factors is essential while maintaining anticoagulation 1
Rhythm Control Strategy
- Continue amiodarone for maintenance of sinus rhythm given the patient's history of severe LV dysfunction that has now improved 1
- Monitor for amiodarone side effects, particularly pulmonary toxicity given the patient's mild airflow obstruction 2
- Perform regular ECG monitoring to assess for QT prolongation, especially with concomitant medications that may interact with amiodarone 2
- Consider dose adjustment of other medications that interact with amiodarone:
Heart Failure Management
- Continue Jardiance (empagliflozin) as SGLT2 inhibitors are beneficial for heart failure patients regardless of diabetes status 1
- Continue Lisinopril as ACE inhibitors improve outcomes in patients with history of heart failure and AF 1, 3
- Continue Lasix (furosemide) as needed for volume management 1
- Continue Lipitor (atorvastatin) for cardiovascular risk reduction 1
Management of Comorbidities
- Strongly encourage CPAP compliance for OSA management, as untreated OSA is associated with AF recurrence 1, 4
- Continue metformin and semaglutide for diabetes management 1
- Continue levothyroxine with regular monitoring of thyroid function 1
- Consider pulmonary consultation for management of airflow obstruction with bronchodilator response 1
Follow-up and Monitoring Plan
- Regular reassessment at least every 6 months or based on clinical need 1
- Monitor for AF recurrence with regular ECGs and consider ambulatory monitoring if symptoms suggest recurrence 1
- Echocardiographic follow-up to ensure maintained improvement in LV function 1
- Regular assessment of medication efficacy and side effects, particularly amiodarone 2
Special Considerations and Pitfalls
- Amiodarone caution: Monitor for pulmonary toxicity given the patient's mild airflow obstruction; perform baseline and periodic pulmonary function tests 2
- Drug interactions: Amiodarone has significant interactions with many medications including beta-blockers, calcium channel blockers, and anticoagulants; dose adjustments may be necessary 2
- OSA management: Failure to address untreated OSA significantly increases risk of AF recurrence despite other appropriate therapies 1, 4
- If AF recurs despite amiodarone therapy, consider catheter ablation, especially given the improved LV function 1
- Avoid nondihydropyridine calcium channel antagonists if heart failure symptoms recur 1