From the Guidelines
The note template for a 73-year-old female with a history of atrial fibrillation and diastolic heart failure presenting with dizziness and irregular heartbeat in an outpatient family medicine setting should prioritize assessment and management according to the AF-CARE pathway, as outlined in the 2024 ESC guidelines for the management of atrial fibrillation 1.
Subjective Information
The template should include documentation of the patient's chief complaint of dizziness and irregular heartbeat, including:
- Onset, duration, severity, aggravating and alleviating factors
- Associated symptoms such as shortness of breath, chest pain, palpitations, syncope, or near-syncope
- Medication adherence and any recent changes to medications
- Potential triggers such as electrolyte abnormalities, thyroid dysfunction, or infection
Objective Information
The objective section should record:
- Vital signs with particular attention to heart rate and rhythm, blood pressure (including orthostatic measurements), oxygen saturation, and temperature
- Physical examination focusing on cardiovascular assessment including heart sounds, rhythm, murmurs, and signs of volume overload
- Neurological examination to evaluate for other causes of dizziness
Assessment
The assessment should address the likely exacerbation of atrial fibrillation and its relationship to diastolic heart failure, considering potential triggers and the need for comorbidity and risk factor management, as emphasized in the 2024 ESC guidelines 1.
- Evaluation of the patient's risk of thromboembolism using the CHA₂DS₂-VASc score
- Assessment of the patient's symptoms and their impact on quality of life
Plan
The plan should include:
- Immediate management of rate or rhythm control with medications like beta-blockers or calcium channel blockers, as recommended in the 2024 ESC guidelines 1
- Anticoagulation assessment and consideration of oral anticoagulants, with a preference for DOACs over VKAs, unless contraindicated
- Laboratory tests including CBC, comprehensive metabolic panel, thyroid function, and BNP
- ECG documentation and consideration of Holter monitoring
- Medication reconciliation and follow-up arrangements, including potential cardiology referral
- Education and counseling on atrial fibrillation management, including lifestyle modifications and adherence to medication regimens, as outlined in the 2024 ESC guidelines 1
From the FDA Drug Label
Apixaban tablets are a prescription medicine used to: • reduce the risk of stroke and blood clots in people who have atrial fibrillation For people taking apixaban tablets for atrial fibrillation: People with atrial fibrillation (a type of irregular heartbeat) are at an increased risk of forming a blood clot in the heart, which can travel to the brain, causing a stroke, or to other parts of the body. Apixaban lowers your chance of having a stroke by helping to prevent clots from forming
The patient is a 73-year-old female with a history of atrial fibrillation (afib) and diastolic heart failure, presenting with dizziness and irregular heartbeat. Given her history of afib, apixaban may be considered to reduce the risk of stroke and blood clots. However, it is crucial to weigh the benefits against the potential risks, including bleeding, which can be serious and rarely may lead to death 2. Key considerations for this patient include:
- Monitoring for signs and symptoms of bleeding
- Managing potential interactions with other medications that increase the risk of bleeding
- Close observation for spinal or epidural blood clots if spinal anesthesia or puncture is planned The patient's dizziness and irregular heartbeat should be evaluated and managed accordingly, considering her underlying conditions and potential medication side effects.
From the Research
Patient Presentation
- 73-year-old female with a history of atrial fibrillation (AF) and diastolic heart failure presenting for dizziness and irregular heartbeat in an outpatient family medicine setting.
Relevant Medical History
- Atrial fibrillation: a condition characterized by an irregular and often rapid heart rate, which can increase the risk of stroke, heart failure, and other heart-related complications 3, 4, 5, 6.
- Diastolic heart failure: a condition where the heart's ability to relax and fill with blood during diastole is impaired, leading to increased pressure and fluid buildup in the lungs and other parts of the body 3, 4, 5, 6.
Diagnostic Considerations
- Echocardiography: a crucial diagnostic tool for assessing left ventricular diastolic function and diagnosing diastolic dysfunction, especially in patients with AF 4, 5.
- Electrocardiography: may show signs of AF, such as irregular rhythm and absence of P waves 3, 4.
- Laboratory tests: may include measurements of natriuretic peptides to help diagnose heart failure with preserved ejection fraction (HFpEF) 5.
Management Approaches
- Pharmacological interventions: may include rate and rhythm control medications for AF, diuretics to manage fluid overload, and medications to address comorbidities such as hypertension and coronary artery disease 3, 4.
- Addressing comorbidities: managing conditions such as hypertension, diabetes, and obesity can help alleviate symptoms and slow disease progression 3, 4, 5, 6.
Clinical Challenges
- Diagnosing diastolic dysfunction and HFpEF in patients with AF can be challenging due to the absence of atrial contraction and variability in cycle length 5.
- A comprehensive clinical evaluation, including echocardiography, laboratory tests, and assessment of symptoms, is necessary to diagnose and manage diastolic heart failure and AF effectively 3, 4, 5, 6.