What is the optimal management plan for an older adult male with a history of atrial fibrillation (A-fib), previous cerebrovascular accident (CVA) with residual right-sided weakness, and current symptoms of palpitations and fatigue, who is taking Eliquis (apixaban) 2.5 mg twice daily and has mild left ventricular hypertrophy (LVH) with normal function, and is scheduled for hernia repair?

Optimal Management Plan for Older Adult Male with Atrial Fibrillation, Post-CVA, and Upcoming Hernia Repair

Continue Eliquis (apixaban) 2.5 mg twice daily for stroke prevention, discontinue aspirin to reduce bleeding risk before hernia repair, and restart metoprolol at the lowest effective dose for rate control given the patient's symptomatic palpitations after discontinuation, while monitoring closely for bradycardia. 1, 2

Anticoagulation Management

Eliquis 2.5 mg twice daily is the correct dose for this patient given he meets at least two of the following criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 2 This reduced dose is specifically indicated in the FDA labeling for stroke prevention in nonvalvular atrial fibrillation. 2

• Discontinue aspirin 81 mg daily immediately to prevent bleeding complications during hernia repair, as the combination of anticoagulation plus antiplatelet therapy significantly increases bleeding risk without additional stroke prevention benefit in atrial fibrillation. 3, 1
• Continue Eliquis uninterrupted through the hernia repair unless the surgeon determines this is a high-bleeding-risk procedure. 2 For low-to-moderate bleeding risk procedures, apixaban should be held for only 24-48 hours before surgery and restarted as soon as adequate hemostasis is established. 2
• The patient's high CHA₂DS₂-VASc score (prior CVA alone = 2 points, plus likely additional points for age/other factors) mandates lifelong anticoagulation regardless of whether he remains in atrial fibrillation or converts to sinus rhythm. 3

Rate Control Strategy

Restart metoprolol at a reduced dose (e.g., 12.5-25 mg twice daily) for rate control, as the patient developed symptomatic palpitations when it was discontinued, indicating inadequate rate control. 1, 4

• The patient's atrial flutter with high burden (percentage not specified but concerning) requires rate control to prevent tachycardia-induced cardiomyopathy, especially given his normal left ventricular function that must be preserved. 3, 1
• Monitor heart rate closely with target resting heart rate <110 bpm using a lenient rate control strategy, which is non-inferior to strict rate control and better tolerated in older adults. 3
• If bradycardia recurs (minimum heart rate concerning as noted in the clinical note), consider adding digoxin as combination therapy rather than using beta-blocker monotherapy at higher doses. 3, 1, 4 Digoxin provides rate control without negative chronotropic effects on sinus rhythm and is particularly useful in older adults with atrial fibrillation. 3, 5
• Document the minimum heart rate from the Holter monitor to establish baseline bradycardia risk before restarting metoprolol. 1

Rhythm Control Consideration

Refer to electrophysiology for pulmonary vein isolation (catheter ablation) should be strongly reconsidered despite the patient's current reluctance, given his symptomatic atrial flutter with high burden and the potential to avoid long-term antiarrhythmic medications. 3

• The patient's normal left ventricular function (ejection fraction preserved), mild LVH, and symptomatic palpitations make him a reasonable candidate for catheter ablation. 3
• Catheter ablation can be performed safely on uninterrupted apixaban, with comparable safety and efficacy to warfarin, eliminating the need for bridging anticoagulation. 6
• Early rhythm control (within 12 months of diagnosis) reduces cardiovascular death and hospitalization in patients with atrial fibrillation and stroke risk factors. 3
• If the patient continues to decline EP referral, document this shared decision-making discussion thoroughly, emphasizing that rhythm control may improve his fatigue and quality of life. 3, 5

Perioperative Management for Hernia Repair

The patient's revised cardiac risk index with low perioperative risk supports proceeding with hernia repair with appropriate anticoagulation management. 1

• Hold Eliquis for 24 hours before surgery (last dose 24 hours pre-op) for low-bleeding-risk hernia repair, or 48 hours for moderate-bleeding-risk procedures, coordinating with the surgeon. 2
• Restart Eliquis 12-24 hours after surgery once adequate hemostasis is achieved, as premature discontinuation increases thrombotic risk. 2
• The normal preoperative troponin and sinus rhythm on EKG are reassuring for perioperative cardiac risk. 1
• No bridging anticoagulation is needed during the brief interruption of apixaban for surgery. 2

Addressing Fatigue and Bradycardia

Evaluate for sleep apnea and optimize rate control to address fatigue, as both uncontrolled atrial fibrillation and sleep-disordered breathing contribute to excessive daytime sleepiness. 1, 5

• The patient's reluctance to pursue sleep study should be revisited, as obstructive sleep apnea is a major modifiable risk factor for atrial fibrillation recurrence and progression. 3, 1
• Bradycardia may be contributing to fatigue - if resting heart rate is consistently <50 bpm with symptoms, metoprolol should be dose-reduced or discontinued, and digoxin considered as an alternative. 1, 4
• Check thyroid function if not recently done, as hypothyroidism can cause both fatigue and bradycardia in older adults. 7

Critical Pitfalls to Avoid

• Never use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in this patient if he develops heart failure, as they are Class III (harm) in heart failure with reduced ejection fraction. 4
• Do not stop anticoagulation based on successful rhythm control, as silent atrial fibrillation recurrences are common and stroke risk persists. 3
• Avoid combining aspirin with apixaban long-term outside of acute coronary syndrome indications, as bleeding risk outweighs any theoretical benefit. 3
• Do not delay hernia repair due to anticoagulation concerns - coordinate with surgery for appropriate perioperative management rather than stopping anticoagulation entirely. 2

Follow-Up Plan

Schedule cardiology follow-up in 3-4 months (rather than waiting 6-12 months as patient requested) to reassess rate control, symptoms, and reconsider EP referral after hernia recovery. 1, 5

• Obtain repeat Holter monitor in 3 months to assess adequacy of rate control on adjusted metoprolol dose and burden of atrial flutter. 1
• Monitor for stroke symptoms and ensure patient/family understand warning signs given his high-risk status with prior CVA. 3
• Reassess functional status and right-sided weakness to determine if rhythm control might improve his mobility and independence. 5
• Renal function monitoring should occur at least annually on apixaban, more frequently if creatinine clearance is borderline. 2