How should we manage an 84‑year‑old male with a 26 mm Edwards SAPIEN transcatheter aortic valve replacement (TAVR), paroxysmal atrial fibrillation on warfarin, chronic obstructive pulmonary disease (COPD), type‑2 diabetes mellitus, hypertension, hyperlipidemia, benign prostatic hyperplasia, elevated pro‑brain natriuretic peptide indicating early heart failure, impaired renal function (stage 3b chronic kidney disease), persistent lower‑extremity edema on furosemide 40 mg daily, who prefers to stay on warfarin and decline left atrial appendage closure, and requires azithromycin prophylaxis for an upcoming dental extraction?

Management Recommendations for 84-Year-Old Male Post-TAVR with Multiple Comorbidities

Immediate Priority: Address Acute Kidney Injury and Volume Overload

The elevated pro-BNP (1343) and worsening renal function (creatinine 2.07, GFR 31) indicate acute decompensated heart failure with cardiorenal syndrome requiring urgent diuretic optimization and close monitoring. 1

Diuretic Management

• Increase furosemide to 80 mg daily (currently on 40 mg) given the significant volume overload evidenced by persistent lower extremity edema and elevated BNP 1
• Monitor daily weights with strict instructions: if weight increases by 3 pounds in 1 day or 5 pounds in 1 week, take an additional 40 mg furosemide that day 1
• Recheck basic metabolic panel (BUN, creatinine, potassium) within 3-5 days after diuretic adjustment to ensure potassium remains stable and renal function does not worsen further 1
• Target net negative fluid balance until lower extremity edema resolves and BNP normalizes 1

Renal Function Monitoring

• The decline from baseline creatinine to 2.07 (GFR 31, stage 3b CKD) requires immediate attention to prevent progression to stage 4 1
• Evaluate for prerenal azotemia versus cardiorenal syndrome: check urinalysis, urine sodium, and fractional excretion of sodium 1
• Continue warfarin with close INR monitoring as warfarin remains appropriate for stage 3b CKD, whereas direct oral anticoagulants have insufficient evidence in this population 1

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Rate Control Strategy for Atrial Fibrillation with COPD

Continue diltiazem 120 mg daily as the preferred rate control agent given his COPD, avoiding beta-blockers which can precipitate bronchospasm. 1

Current Rate Control Assessment

• Current heart rate of 84 bpm on diltiazem 120 mg daily is acceptable for resting rate control 1
• Assess heart rate during exercise or activity to ensure adequate rate control during exertion, as resting rate alone is insufficient 1
• If exercise heart rate exceeds 110-120 bpm, increase diltiazem to 180 mg daily or add digoxin 0.125 mg daily for additional rate control 1

Rationale for Calcium Channel Blocker Preference

• Nondihydropyridine calcium channel antagonists (diltiazem) are Class I recommended for rate control in atrial fibrillation with COPD to avoid beta-blocker-induced bronchospasm 1
• The combination of diltiazem and digoxin is reasonable if monotherapy fails to achieve adequate rate control during activity 1

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Anticoagulation Management: Continue Warfarin

Respect the patient's informed preference to continue warfarin rather than pursue left atrial appendage closure or switch to a DOAC. 1, 2

Warfarin Continuation Justification

• Patient has paroxysmal atrial fibrillation post-TAVR with mechanical valve replacement, making anticoagulation mandatory 1, 2
• Target INR 2.0-3.0 for atrial fibrillation with bioprosthetic valve (TAVR is considered bioprosthetic) 2
• With stage 3b CKD (GFR 31), warfarin is reasonable and preferred over DOACs, which lack evidence in end-stage or near-end-stage renal disease 1
• Patient reports no bleeding issues and tolerates monthly INR monitoring well, supporting continuation 2

Warfarin Monitoring in Context of Renal Dysfunction

• Evaluate renal function at least annually and more frequently given current acute kidney injury 1
• Continue monthly INR monitoring through the managing organization as currently established 2
• Avoid adding antiplatelet therapy (aspirin or clopidogrel) to warfarin given bleeding risk in elderly patients with multiple comorbidities 1

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Antibiotic Prophylaxis for Dental Procedure

Azithromycin 500 mg (not 5 mg as written) taken 1 hour prior to dental procedure is appropriate given penicillin allergy. 3

Endocarditis Prophylaxis Post-TAVR

• All patients with prosthetic valves (including TAVR) require antibiotic prophylaxis for dental procedures per AHA/ACC guidelines 3
• Azithromycin 500 mg orally 1 hour before the procedure is the correct alternative for penicillin-allergic patients 3
• Encourage optimal dental hygiene to minimize future invasive dental procedures and infection risk 3

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Post-TAVR Surveillance and Follow-Up

Echocardiographic Monitoring

• Perform echocardiogram now given elevated BNP (1343) to assess for: 1, 3
  • Paravalvular regurgitation progression
  • TAVR valve function and gradients
  • Left ventricular ejection fraction changes
  • Evidence of valve thrombosis (though rare with warfarin) 4
• Continue annual echocardiography as previously established for long-term TAVR surveillance 1

Clinical Follow-Up Schedule

• Cardiology follow-up within 1-2 weeks to reassess volume status, renal function, and response to increased diuretics 1
• Continue annual cardiology follow-up for TAVR surveillance after acute issues resolve 1
• Primary care follow-up every 3 months for management of diabetes, hypertension, and COPD 3

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COPD Management Considerations

Avoiding Exacerbations

• The recent COPD exacerbation requiring IV antibiotics and steroids highlights vulnerability to recurrent exacerbations 1
• Ensure patient has rescue inhaler (albuterol) and maintenance therapy (long-acting bronchodilator ± inhaled corticosteroid) optimized 1
• Avoid beta-blockers permanently given COPD and recent exacerbation history 1
• Consider pulmonology referral if not already established for COPD optimization 1

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Critical Pitfalls to Avoid

Do Not Switch to DOACs

• Direct oral anticoagulants (dabigatran, rivaroxaban, apixaban) are not recommended with GFR 31 due to lack of evidence and increased bleeding risk in advanced CKD 1
• Dabigatran is specifically contraindicated with creatinine clearance <15 mL/min and not recommended with mechanical valves 1

Do Not Add Antiplatelet Therapy to Warfarin

• Avoid triple therapy (warfarin + aspirin + clopidogrel) or even dual therapy (warfarin + aspirin) given high bleeding risk in elderly post-TAVR patients 1, 5
• Warfarin monotherapy is sufficient for stroke prevention in atrial fibrillation post-TAVR when no recent PCI 5, 4

Do Not Overlook Cardiorenal Syndrome

• The combination of elevated BNP and worsening renal function suggests cardiorenal syndrome requiring aggressive diuresis balanced against further renal injury 1
• Monitor electrolytes closely (especially potassium) with diuretic escalation given baseline potassium 4.2 and CKD 1

Do Not Delay Echocardiogram

• Elevated BNP from 58 to 1343 represents a significant change requiring imaging to exclude structural complications (paravalvular leak progression, valve thrombosis, new valvular dysfunction) 1, 3

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Summary Algorithm for Management

1. Immediate (within 3-5 days):

   • Increase furosemide to 80 mg daily 1
   • Recheck BMP, BNP 1
   • Order echocardiogram 1, 3
   • Prescribe azithromycin 500 mg for dental prophylaxis 3

2. Short-term (1-2 weeks):

   • Cardiology follow-up to assess diuretic response and echocardiogram results 1
   • Assess exercise heart rate; adjust diltiazem or add digoxin if needed 1
   • Ensure INR therapeutic (2.0-3.0) 2

3. Ongoing:

   • Continue warfarin with monthly INR monitoring 2
   • Continue diltiazem 120 mg daily (or higher if exercise rate uncontrolled) 1
   • Daily weights with diuretic adjustment protocol 1
   • Annual echocardiography and cardiology follow-up 1
   • Optimize COPD management to prevent exacerbations 1