What is the recommended management for a 71-year-old male with a history of atrial fibrillation (AFib), CHA2DS2-VASc (Chad Vasc) risk score of 1, not on anticoagulation, experiencing symptoms suggestive of recurrent AFib with tachycardia, currently on atenolol (beta blocker) 12.5 mg twice daily and flecainide (anti-arrhythmic) 50 mg twice daily?

From the Guidelines

For a 71-year-old male with a history of AFib, a CHA₂DS₂-VASc score of 1, and symptoms suggesting recurrent AFib with rapid heart rate, a "pocket" or "pill-in-pocket" approach can be implemented, but anticoagulation therapy should be considered due to the increased risk of stroke with age, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1. The patient's current medications, atenolol 12.5 mg b.i.d. and flecainide 50 mg b.i.d., should be continued as prescribed.

• The pill-in-pocket approach can be used to provide a higher dose of antiarrhythmic medication during an acute episode to convert the rhythm back to normal sinus rhythm.
• The patient should take flecainide 200-300 mg as a single oral dose at the onset of symptoms, rest for 3-4 hours after taking the medication, and use this approach no more than once every 24 hours.
• The patient should contact his physician if symptoms persist beyond 24 hours after taking the medication. Key considerations for this patient include:
• The risk of stroke increases with age, even with a relatively low CHA₂DS₂-VASc score, and anticoagulation therapy should be discussed, as recommended by the 2024 ESC guidelines 1.
• The patient's symptoms and medical history should be thoroughly evaluated to determine the best course of treatment.
• The patient should be educated on the risks and benefits of anticoagulation therapy and the pill-in-pocket approach, and a shared decision-making approach should be used to determine the best treatment plan, as recommended by the 2024 ESC guidelines 1.

From the FDA Drug Label

For patients with PAF the recommended starting dose is 50 mg every 12 hours. Flecainide doses may be increased in increments of 50 mg bid every four days until efficacy is achieved For PAF patients, a substantial increase in efficacy without a substantial increase in discontinuations for adverse experiences may be achieved by increasing the flecainide dose from 50 mg to 100 mg bid.

The patient is already on flecainide 50 mg b.i.d. and can be increased to 100 mg b.i.d. to try to achieve better control of the arrhythmia, as the current dose may not be sufficient to prevent recurrence of AFib. 2

From the Research

Patient's Current Condition

• The patient is a 71-year-old male with a history of atrial fibrillation (AFib) and a CHAD Vasc risk score of 1.
• He is not currently on anticoagulation therapy.
• The patient is experiencing symptoms that may indicate a return to AFib, including a fast pulse rate.
• His current medication regimen includes atenolol 12.5 mg b.i.d. and flecainide 50 mg b.i.d.

Anticoagulation Therapy for AFib

• According to the study 3, anticoagulation therapy is a crucial aspect of managing AFib to prevent thrombi and stroke.
• The study discusses the use of direct oral anticoagulants (DOACs) such as dabigatran, rivaroxaban, apixaban, and edoxaban, which have been shown to reduce the risk of intracranial hemorrhage compared to warfarin.
• The patient's current medication regimen does not include anticoagulation therapy, which may be a concern given his history of AFib and symptoms suggesting a potential return to AFib.

Considerations for Anticoagulation Therapy

• The study 3 highlights the importance of risk stratification schemes in determining the need for anticoagulation therapy in patients with AFib.
• The patient's CHAD Vasc risk score of 1 may indicate a lower risk of stroke, but his symptoms and history of AFib suggest that anticoagulation therapy may still be necessary.
• The use of reversal agents such as Idarucizumab for dabigatran and Andexanet alfa for apixaban and rivaroxaban may alleviate concerns about the lack of reversal agents for DOACs.