What is the best management plan for an elderly female patient with atrial fibrillation (A-fib) and heart failure with preserved ejection fraction (HFpEF), who has a history of intolerance to certain medications and requires stroke prevention?

Management of Atrial Fibrillation and HFpEF in an Elderly Patient with Anticoagulation Intolerance

This patient requires aggressive desensitization to apixaban or alternative anticoagulation strategy given her high stroke risk with paroxysmal atrial fibrillation, combined with optimization of HFpEF therapy including SGLT2 inhibitors and management of comorbidities. 1

Stroke Prevention: The Critical Priority

Oral anticoagulation is mandatory for this patient with paroxysmal atrial fibrillation and elevated CHA2DS2-VASc score to prevent ischemic stroke and thromboembolism. 1

Anticoagulation Strategy

• Direct oral anticoagulants (DOACs) are recommended in preference to vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation. 1 The 2024 ESC guidelines specifically state DOACs reduce intracranial hemorrhage by 50% compared to warfarin. 1

• For patients experiencing allergic reactions to one DOAC (the "itching" described with apixaban), switching to an alternative DOAC with a different chemical structure should be attempted before abandoning anticoagulation entirely. 1 Consider rivaroxaban, dabigatran, or edoxaban as alternatives. 1

• Gradual dose escalation with antihistamine premedication may allow successful desensitization to apixaban if alternative DOACs are not tolerated. 2 The FDA label indicates apixaban can be dose-adjusted based on patient characteristics (age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL warrant 2.5 mg twice daily). 2

• If all DOACs are genuinely contraindicated due to allergic reactions, warfarin with a target INR of 2.0-3.0 and time in therapeutic range >70% becomes necessary despite higher intracranial hemorrhage risk. 1

• Left atrial appendage occlusion (LAAO) should be considered if all oral anticoagulants are contraindicated or not tolerated, as this is the source of most thrombi in nonvalvular atrial fibrillation. 1

Common Pitfall to Avoid

A reduced dose of DOAC therapy is not recommended unless patients meet DOAC-specific criteria to prevent underdosing and avoidable thromboembolic events. 1 The "purple hands and arms" described does not constitute a valid reason for dose reduction without meeting specific criteria (age ≥80, weight ≤60 kg, or creatinine ≥1.5 mg/dL). 2

Heart Failure with Preserved Ejection Fraction Management

Evidence-Based Medical Therapy

• SGLT2 inhibitors should be initiated regardless of diabetes status, as they reduce the risk of worsening heart failure or cardiovascular death in HFpEF. 3 Recent trials demonstrate consistent benefit whether patients have atrial fibrillation or not at enrollment. 3

• Mineralocorticoid receptor antagonists (MRAs) are recommended for HFpEF management and may provide additional benefit in patients with concurrent atrial fibrillation. 3

• Loop diuretics remain first-line treatment for fluid overload, with initial parenteral doses equal to or greater than chronic oral daily doses. 4 Serial adjustments based on response are essential. 4

• Rigorous blood pressure control is fundamental, as over 90% of HFpEF patients have hypertension. 5 ACE inhibitors or ARBs are recommended as first-line therapy for blood pressure management and may help prevent atrial fibrillation progression. 1

Monitoring During Therapy

• Electrolytes, urea nitrogen, and creatinine require monitoring during medication titration, especially with diuretics. 4

• BNP levels should be tracked to assess response to therapy and guide management decisions. 4

Atrial Fibrillation Rhythm Management in HFpEF

Rate Control Strategy

• For patients with HFpEF and atrial fibrillation, beta-blockers are recommended as first-line therapy for rate control unless contraindicated. 6 The 2024 ACC/AHA guidelines specifically endorse this approach. 6

• Non-dihydropyridine calcium channel blockers (diltiazem or verapamil) are recommended when beta-blockers are inadequate or contraindicated for rate control. 6, 4 Verapamil may improve exercise capacity and symptoms in HFpEF patients. 4

• Target heart rate should be <100 bpm for rate control in stable patients. 6

• Digoxin may be considered for additional rate control in HFpEF patients, though it should not be first-line. 6

Rhythm Control Considerations

• Catheter ablation should be considered in selected patients with HFpEF and paroxysmal or early persistent atrial fibrillation, as it may improve cardiovascular outcomes, quality of life, and survival compared to medical therapy. 7, 3 The EAST-AFNET 4 trial demonstrated that early rhythm-control therapy reduces adverse cardiovascular outcomes in patients with recent atrial fibrillation and cardiovascular conditions including heart failure. 3

• For this patient with paroxysmal atrial fibrillation triggered by pneumonia/sepsis, initial rate control with reassessment is reasonable, but catheter ablation should be discussed if symptomatic episodes recur. 7, 3

• Amiodarone is the preferred antiarrhythmic drug if pharmacological rhythm control is chosen in HFpEF, though the patient's reported "nightmares" (likely representing amiodarone neurotoxicity) make this problematic. 1, 6

Critical Pitfall

Non-dihydropyridine calcium channel blockers and high-dose beta-blockers should not be given to patients with decompensated heart failure. 6, 4 Ensure the patient is euvolemic before initiating or uptitrating these agents. 4

Management of Comorbidities

Pneumonia and COPD

• The diffuse centrilobular emphysema identified requires optimization of pulmonary management, as chronic obstructive pulmonary disease is a common comorbidity that can exacerbate both atrial fibrillation and heart failure. 1

• Beta-blocker selection should favor cardioselective agents (metoprolol, bisoprolol) rather than non-selective agents in patients with emphysema. 1

Weight and Lifestyle Optimization

• Maintaining normal weight (BMI 20-25 kg/m²) is recommended to prevent atrial fibrillation progression. 1

• Maintaining an active lifestyle with 150-300 minutes per week of moderate intensity aerobic physical activity is recommended. 1

• Supervised exercise training should be considered after stabilization as it provides substantial improvements in exercise capacity and quality of life in HFpEF. 4

Integrated Care Approach (ABC Pathway)

Patients with atrial fibrillation and HFpEF with multiple comorbidities benefit most from adherence to the ABC (Atrial Fibrillation Better Care) pathway: 3

• A = Avoid stroke with anticoagulation (as detailed above) 3
• B = Better symptom management with rate or rhythm control (as detailed above) 3
• C = Cardiovascular and Comorbidity optimization (blood pressure, heart failure therapy, weight management) 3

Medication Reconciliation and Adherence

Given the patient's confusion about medications and reported non-adherence, the following steps are essential:

• Provide written medication schedules with clear explanations of each medication's purpose, emphasizing stroke prevention with anticoagulation. 1

• Simplify the regimen where possible, using once-daily formulations when available. 1

• Schedule close follow-up (within 2-4 weeks) to assess tolerance of anticoagulation and heart failure medications. 1, 4

• Consider involving pharmacy services or home health for medication management support in this elderly patient with demonstrated adherence challenges. 1

Reassessment Strategy

Individualized reassessment of thromboembolic risk is recommended at periodic intervals to ensure anticoagulation is maintained in appropriate patients. 1 For this patient, reassessment should occur at each visit given her history of stopping anticoagulation. 1