What is the optimal management plan for an elderly female patient with atrial fibrillation (AF), chronic heart failure (CHF) with preserved ejection fraction, combined pre and post capillary pulmonary hypertension, moderate to severe tricuspid regurgitation (TR), diabetes, hypertension, hyperlipidemia, history of gastrointestinal (GI) bleed, and impaired renal function, currently on Eliquis (apixaban) 5 mg twice daily, Protonix (pantoprazole), levothyroxine, potassium chloride, simvastatin, and spironolactone, with a Medtronic biventricular (bivir) pacemaker?

Optimal Management Plan for Elderly Female with Atrial Fibrillation, HFpEF, and Multiple Comorbidities

Continue Eliquis 5 mg twice daily without interruption, optimize rate control with beta-blocker therapy, aggressively manage volume status with diuretics, and initiate SGLT2 inhibitor therapy for HFpEF while maintaining comprehensive comorbidity management. 1, 2

Anticoagulation Management

Your patient should remain on Eliquis 5 mg twice daily indefinitely given her CHA₂DS₂-VASc score of 5, regardless of rhythm control success. 1, 2, 3

• The current Eliquis dose is appropriate as she does not meet criteria for dose reduction (requires at least 2 of: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL). 3
• Her history of GI bleeding on anticoagulation necessitates continued Protonix (pantoprazole) for gastroprotection. 2
• Critical pitfall: Do not discontinue anticoagulation even if sinus rhythm is achieved or maintained, as her stroke risk remains elevated independent of rhythm status. 1, 2
• Monitor for bleeding complications given her history, but the presence of severe TR and HFpEF actually reinforces the need for continued anticoagulation due to increased stroke risk from atrial enlargement. 2, 4

Rate Control Strategy

Beta-blockers are the first-line agent for rate control in this patient with HFpEF and should be optimized before considering additional agents. 1, 2

• Target lenient rate control with resting heart rate <110 bpm initially, with stricter control (<80 bpm) only if symptoms persist. 1
• Her current ventricular rate in the 60s without AV blockers suggests adequate intrinsic rate control, but assess heart rate response during activity as exercise intolerance is common in HFpEF. 1, 2
• If beta-blocker alone is insufficient, add digoxin rather than calcium channel blockers, as digoxin is effective for resting heart rate control in HFpEF and can be safely combined with beta-blockers. 1, 2
• Avoid calcium channel blockers (diltiazem, verapamil) in this patient due to her moderate-to-severe TR and likely RV dysfunction, as these agents can worsen RV function. 1, 2
• Monitor heart rate during exercise and adjust therapy accordingly, as rate control adequacy must be assessed during activity, not just at rest. 1, 2

Heart Failure Management with Preserved Ejection Fraction

Initiate SGLT2 inhibitor therapy (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) immediately as this is the only disease-modifying therapy proven to reduce mortality and HF hospitalization in HFpEF. 1, 5

• SGLT2 inhibitors are recommended regardless of diabetes status and have demonstrated cardiovascular death and HF hospitalization benefits in patients with HFpEF and AF. 1, 5
• Continue spironolactone as she already tolerates this medication; mineralocorticoid receptor antagonists provide additional benefit in HFpEF, particularly with her combined pre- and post-capillary pulmonary hypertension. 1, 5, 6
• Aggressive diuretic therapy is essential given her moderate-to-severe TR, pulmonary hypertension, and likely elevated filling pressures; adjust loop diuretic dose based on congestion status at each visit. 1, 2, 5
• Monitor potassium closely given combined use of spironolactone and potassium chloride supplementation; may need to reduce or discontinue potassium supplementation. 5

Volume Status and Tricuspid Regurgitation Management

Optimize volume status aggressively as moderate-to-severe TR creates a vicious cycle of right heart failure and worsening TR. 2, 7, 4

• Assess for signs of congestion at rest and during activity at every visit, including jugular venous pressure, peripheral edema, hepatomegaly, and ascites. 2, 5
• Titrate diuretics to achieve euvolemia without causing hypotension or prerenal azotemia, monitoring renal function and electrolytes regularly. 1, 5
• The presence of significant TR in AF patients with preserved LVEF independently predicts adverse outcomes including heart failure and mortality, making aggressive management critical. 4
• Common pitfall: Avoid excessive diuresis which can lead to hypotension and impaired tolerance of other guideline-directed medical therapies. 5

Rhythm Control Consideration

A rhythm-control strategy should be considered if symptoms persist despite optimized rate control and volume management, but anticoagulation must continue regardless. 1, 2

• Given her biventricular pacemaker, she has device capability for rhythm monitoring and potential pacing support if needed. 2
• If rhythm control is pursued, amiodarone is the preferred antiarrhythmic given her structural heart disease (HFpEF, TR, pulmonary hypertension), though it should be reserved for symptomatic patients. 1
• Catheter ablation may be considered in experienced centers if she remains symptomatic despite medical therapy, though success rates are lower in patients with significant structural heart disease. 1
• AV node ablation with permanent pacing is reasonable if pharmacological rate control fails or is not tolerated, but only after adequate trials of medical therapy. 1, 2

Comorbidity Management

Comprehensive risk factor management is essential and directly impacts AF recurrence, progression, and overall outcomes. 1

• Hypertension control: Target blood pressure <130/80 mmHg using her current regimen; blood pressure lowering reduces AF recurrence and cardiovascular events. 1
• Diabetes management: Continue current diabetes therapy but prioritize SGLT2 inhibitors given their dual benefit for glycemic control and HF outcomes. 1
• Hyperlipidemia: Continue simvastatin for cardiovascular risk reduction, particularly given her coronary calcification and sluggish flow on prior catheterization. 1
• Thyroid function: Continue levothyroxine with regular TSH monitoring, as both hypo- and hyperthyroidism can exacerbate AF and HF. 1, 8

Monitoring and Follow-up Parameters

Establish a structured monitoring schedule to detect early decompensation and optimize therapy. 1, 2

• Assess volume status, vital signs, and weight at each visit (initially every 3-6 months, then annually if stable). 1, 5
• Monitor renal function and electrolytes regularly given diuretic therapy, spironolactone, and potential for contrast-induced nephropathy from prior procedures. 5, 3
• Evaluate exercise tolerance and functional capacity to guide rate control adjustments and assess HF progression. 1, 2, 5
• Perform annual echocardiography to assess TR progression, pulmonary pressures, and ventricular function. 1, 7
• Review pacemaker interrogation data for AF burden, ventricular pacing percentage, and arrhythmia detection. 1

Critical Pitfalls to Avoid

• Never discontinue anticoagulation based on rhythm status alone; her CHA₂DS₂-VASc score mandates lifelong anticoagulation. 1, 2, 3
• Do not delay SGLT2 inhibitor initiation; this is the only proven mortality-reducing therapy in HFpEF and should be started immediately. 1, 5
• Avoid calcium channel blockers given her RV dysfunction from severe TR; use beta-blockers and digoxin for rate control instead. 1, 2
• Do not over-diurese; excessive volume depletion can worsen renal function and limit tolerance of other therapies. 5
• Avoid combining multiple AV nodal blocking agents without careful monitoring for bradycardia, particularly given her pacemaker. 1