What is the optimal management plan for a patient with a history of CAD, TAVR, A-fib, HTN, HLD, OSA, COPD, pemphigus vulgaris, DVT on Eliquis, colon cancer, and CVA on Plavix?

Optimal Management Plan for Complex Multimorbid Patient Post-TAVR and Watchman

Anticoagulation Strategy

This patient should continue Eliquis (apixaban) 5 mg twice daily as monotherapy and discontinue Plavix (clopidogrel), given her Watchman device placement, completed post-TAVR period, and history of bleeding complications. 1, 2

Rationale for Anticoagulation Monotherapy

• Discontinue Plavix immediately - The patient has a Watchman device (placed 9/30/2025) which eliminates the long-term need for anticoagulation specifically for atrial fibrillation, but she requires continued anticoagulation for her RLE DVT history 1

• Continue full-dose Eliquis 5 mg twice daily for DVT treatment, as she is beyond the acute treatment phase and requires extended anticoagulation given her unprovoked/provoked DVT with ongoing risk factors (malignancy history, immobilization during hospitalizations) 3

• Avoid dual antiplatelet plus anticoagulation therapy - The combination of aspirin with rivaroxaban (and by extension, other oral anticoagulants) increases major bleeding risk without clear benefit in stable CAD, and this patient has already experienced bleeding complications requiring Plavix discontinuation 1, 2

• The 2024 meta-analysis demonstrates that oral anticoagulant monotherapy significantly reduces major bleeding (RR 0.55) compared to dual antithrombotic therapy in patients with AF and stable CAD, with similar rates of ischemic events and mortality 2

Post-TAVR Management

The patient is now 6+ weeks post-TAVR (procedure 10/29/2025) and has completed the critical early post-procedural period, allowing for anticoagulation simplification. 1, 4

TAVR-Specific Considerations

• Monitor for subclinical valve thrombosis with serial echocardiography at 1 month, 6 months, and annually, particularly given the moderate pericardial effusion noted on 12/3/2024 echo 4

• Apixaban has been studied post-TAVR in the ATLANTIS trial as an alternative to standard antiplatelet therapy, though results are pending; current evidence supports its safety in this population 4

• The 26 mm Medtronic Evolut valve function should be assessed for gradients and effective orifice area to ensure no prosthetic valve dysfunction contributing to her symptoms 1

Coronary Artery Disease Management

Optimize medical management for her significant LAD disease (70-80% distal stenosis) with high-intensity statin therapy and address the suspected myocardial bridging component. 1

CAD Optimization Strategy

• Initiate or uptitrate high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) targeting LDL-C <70 mg/dL, as lipid-lowering offers robust ischemic risk reduction with favorable safety profile 1

• Beta-blocker therapy is critical for both her CAD and rate control in paroxysmal atrial fibrillation; ensure adequate dosing for heart rate control and anti-ischemic effect 1, 5

• The distal LAD lesion with suspected myocardial bridging is best managed medically rather than with revascularization, as the catheterization report recommended continued medical optimization 1

• ACE inhibitor or ARB therapy should be continued or initiated given her CAD, particularly with the moderate LVH noted on recent echo 1

Heart Failure and Pericardial Effusion Management

The moderate pericardial effusion (1-2 cm) without tamponade physiology requires close surveillance and investigation of etiology, while optimizing diuretic therapy for recurrent CHF exacerbations. 1

HF and Effusion Strategy

• Serial echocardiography every 4-6 weeks to monitor pericardial effusion progression, as this is new from 8/8/2024 and could represent post-procedural complication, uremic pericarditis (though creatinine not provided), malignancy-related, or autoimmune (pemphigus vulgaris on chronic prednisone) 1

• Maintain euvolemia with oral diuretics (loop diuretic ± thiazide if needed) given her recurrent admissions for acute-on-chronic hypoxic respiratory failure secondary to CHF exacerbations 1

• Consider SGLT2 inhibitor addition (dapagliflozin 10 mg or empagliflozin 10 mg daily) which offers CV mortality reduction, HF hospitalization reduction, and renal protection across her spectrum of comorbidities, even with preserved EF 1

• The supranormal LVEF >70% with moderate concentric LVH raises concern for hypertrophic cardiomyopathy or cardiac amyloidosis; cardiac MRI with late gadolinium enhancement should be performed to differentiate underlying pathophysiology, as this impacts prognosis and management 1

Electrolyte Management

Aggressive potassium repletion and monitoring is essential given her recurrent hypokalemia, diuretic use, and chronic prednisone therapy. 1

• Target serum potassium >4.0 mEq/L to reduce arrhythmia risk in her paroxysmal AF and post-TAVR state; consider potassium-sparing diuretic (spironolactone 12.5-25 mg daily) if not contraindicated by renal function 1

• Monitor magnesium levels and maintain >2.0 mg/dL, as hypomagnesemia often accompanies hypokalemia with diuretic therapy and increases arrhythmia risk 1

Respiratory Management

Optimize COPD and OSA management to reduce CHF exacerbation triggers and improve overall functional status. 1

• Continue home oxygen 2L and ensure compliance with CPAP/BiPAP for OSA, as sleep-disordered breathing worsens heart failure and increases AF burden 1

• Pulmonary function testing and optimization of inhaled therapy to minimize COPD exacerbations that precipitate cardiac decompensation 1

Medication Reconciliation and Simplification

The ABCDE mnemonic guides comprehensive secondary prevention: Aspirin/Anticoagulation, Beta-blockers/Blood pressure, Cholesterol/Cigarettes, Diet/Diabetes, Education/Exercise. 1

Current Medication Framework

• A: Anticoagulation - Eliquis 5 mg BID (discontinue Plavix) 1, 2
• B: Beta-blocker - Continue/optimize dosing for rate control and anti-ischemic effect 1, 5
• B: Blood pressure - ACE-I/ARB for CAD and LVH 1
• C: Cholesterol - High-intensity statin targeting LDL <70 mg/dL 1
• D: Diuretic - Loop diuretic for volume management, consider SGLT2i addition 1
• E: Electrolytes - Aggressive K+ repletion, consider K+-sparing diuretic 1

Critical Monitoring Parameters

Establish a structured follow-up schedule with specific monitoring targets to prevent readmissions and detect complications early. 1

• Weekly telephone follow-up for first 4 weeks to reinforce education, monitor symptoms, assess medication adherence, and gauge recovery progress 1

• Echocardiography at 1 month, 3 months, and 6 months to monitor TAVR valve function, pericardial effusion, and LV function 1, 4

• Laboratory monitoring every 2-4 weeks initially: electrolytes (K+, Mg2+), renal function, BNP trending 1

• Cardiology follow-up within 2 weeks of current visit, then monthly until stable 1

Specific Pitfalls to Avoid

• Do not use aspirin in combination with Eliquis - This patient has already demonstrated bleeding complications, and the combination increases major bleeding without proven benefit in her stable CAD 1, 2

• Do not use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) if her LVEF drops below 50%, as these have negative inotropic effects 5, 6

• Do not ignore the new pericardial effusion - This requires investigation and serial monitoring as it could represent serious post-procedural complication or systemic disease 1

• Do not undertitrate beta-blocker therapy - Adequate dosing is essential for both CAD management and AF rate control 1, 5

• Do not delay cardiac MRI if the LVH etiology remains unclear, as infiltrative cardiomyopathy (amyloidosis) has specific treatment implications and prognosis 1