What are the next steps in managing an elderly patient with a history of atrial fibrillation on Eliquis, presenting with generalized weakness, body aches, headache, and malaise, transient chest pain, and hypertension, with pending CBC, CMP, urinalysis, COVID and Flu swabs, and EKG results?

Immediate Next Steps: Obtain Serial Troponins and Continuous Cardiac Monitoring

Given the transient chest pain en route to the ER in an elderly patient with AFib on anticoagulation, you must immediately order serial troponins (now and at 3 hours) and place the patient on continuous cardiac monitoring to rule out acute coronary syndrome, even though she is currently chest pain-free. 1

Critical Immediate Actions

Cardiac Workup for Transient Chest Pain

• Order serial troponins immediately (baseline and repeat at 3 hours minimum) to exclude myocardial infarction, as transient chest pain in an elderly patient with cardiovascular risk factors requires exclusion of ACS regardless of current symptom status 1
• Place on continuous cardiac monitoring to detect any arrhythmic complications or recurrent AFib episodes that may correlate with symptoms 1
• Review the EKG specifically for: signs of acute or remote MI, LV hypertrophy, bundle branch block, ischemic changes, QT interval prolongation, and confirm AFib rhythm versus other arrhythmias 1

Blood Pressure Management

• Address the elevated BP (170/92 mmHg) urgently as uncontrolled hypertension in AFib patients is independently associated with 53% increased risk of stroke or systemic embolism (HR 1.53,95% CI 1.25-1.86) and 50% increased risk of ischemic stroke 2
• Avoid aggressive BP reduction in the acute setting; gradual control is preferred unless hypertensive emergency is present 3

Essential Diagnostic Evaluation Already Ordered

Review Pending Results Systematically

• CBC: Assess for infection (elevated WBC), anemia contributing to weakness, or thrombocytopenia affecting bleeding risk on Eliquis 1
• CMP: Evaluate renal function (critical for Eliquis dosing and stroke risk), electrolyte abnormalities (hypokalemia/hypomagnesemia can exacerbate AFib), liver function, and glucose 1
• Urinalysis: Rule out urinary tract infection as precipitant for decompensation 1
• COVID/Flu swabs: Identify infectious etiology for constitutional symptoms 4

Additional Testing Required

Mandatory Cardiac Evaluation

• Transthoracic echocardiogram to assess: LV size and function, valvular disease, left atrial size, peak RV pressure (pulmonary hypertension), LV hypertrophy, and pericardial disease 1
• Thyroid function tests (TSH) are mandatory for first presentation or when ventricular rate is difficult to control, as hyperthyroidism can precipitate AFib and worsen symptoms 1

Chest Radiograph

• Obtain chest X-ray to evaluate lung parenchyma and pulmonary vasculature, particularly given constitutional symptoms that could represent pneumonia or heart failure 1

Risk Stratification

Stroke Risk Assessment

• Calculate CHA₂DS₂-VASc score to confirm appropriateness of current anticoagulation with Eliquis 1
• Elderly age alone likely places her at elevated stroke risk requiring anticoagulation 3, 5
• Verify Eliquis adherence and dosing (should be 5 mg twice daily, or 2.5 mg twice daily if meets dose-reduction criteria: age ≥80 years, weight ≤60 kg, or creatinine ≥1.5 mg/dL) 6

Bleeding Risk

• Review for signs of bleeding given anticoagulation, particularly with constitutional symptoms 1, 6
• Major bleeding risk with apixaban is 1.71% per patient-year but must be balanced against stroke prevention benefit 6

Determine AFib Type and Duration

Establish Timeline

• Clarify if this is first diagnosed, paroxysmal, persistent, or permanent AFib through history and review of prior records 1
• Determine if patient is currently in AFib or sinus rhythm when EKG results available 1
• If AFib duration >48 hours or unknown, consider need for transesophageal echocardiography before any cardioversion attempt 1

Search for Precipitating Factors

Identify Reversible Causes

• Infection: Most common precipitant in elderly patients presenting with constitutional symptoms 1
• Electrolyte abnormalities: Check potassium, magnesium, calcium 1
• Medication non-adherence: Verify Eliquis compliance 1
• Alcohol consumption: Obtain detailed history 1
• Cardiac ischemia: Hence the need for troponins given chest pain history 1

Disposition Planning

Admission Criteria

• Strong consideration for admission given: transient chest pain requiring ACS rule-out, elevated BP requiring management, constitutional symptoms of unclear etiology, and elderly age with multiple comorbidities 1, 3
• Continuous monitoring allows assessment of ventricular rate control and detection of any hemodynamic instability 1, 3

Common Pitfalls to Avoid

• Do not dismiss transient chest pain simply because patient is currently asymptomatic; elderly patients and those with AFib may have atypical presentations of ACS 1
• Do not overlook infection as precipitant; constitutional symptoms (weakness, body aches, malaise) may represent serious infection requiring urgent treatment 1
• Do not assume adequate anticoagulation without verifying medication adherence and appropriate dosing based on renal function 1, 6