From the Guidelines
I strongly recommend optimizing this patient's medication regimen to prioritize atrial fibrillation management, stroke prevention, and blood pressure control while carefully considering her heart rate concerns and age-related factors, as outlined in the 2024 ESC guidelines for the management of atrial fibrillation 1 and the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 2. Given the patient's age and the presence of atrial fibrillation, it is crucial to balance the management of her heart rate, blood pressure, and stroke risk. The current regimen includes Eliquis (apixaban) for stroke prevention, which is appropriate according to the guidelines that recommend oral anticoagulants for all eligible patients with atrial fibrillation, except those at low risk of incident stroke or thromboembolism 1. For blood pressure management, the patient's systolic blood pressure is slightly elevated at 140/62. Considering her age (85 years) and the guidelines' recommendations, caution is advised in initiating or intensifying blood pressure-lowering treatment in older patients (aged ≥85 years) due to the potential for orthostatic hypotension and other side effects 2. However, the guidelines suggest that BP-lowering treatment should be started based on individual clinical judgment and shared decision-making. The patient's current lisinopril dose of 20 mg twice daily could be consolidated to 20 mg once daily to potentially reduce the risk of low heart rates, and the atenolol dose reduction to 25 mg was appropriate given the low heart rates on Holter monitoring. Further reduction or discontinuation of atenolol should be considered if bradycardia persists, balancing the need for rate control with the risk of excessive bradycardia. Adding a calcium channel blocker like amlodipine 5 mg daily could help achieve better blood pressure control without worsening bradycardia, but this decision should be made cautiously, considering the patient's overall clinical status and potential for drug interactions. Regular monitoring of heart rate, blood pressure, and symptoms is essential, with follow-up in 2-4 weeks to assess the effectiveness of these changes and adjust the treatment plan as necessary to prioritize the patient's morbidity, mortality, and quality of life outcomes.
From the FDA Drug Label
DOSAGE & ADMINISTRATION Hypertension The initial dose of atenolol is 50 mg given as one tablet a day either alone or added to diuretic therapy. Elderly Patients or Patients with Renal Impairment Atenolol is excreted by the kidneys; consequently dosage should be adjusted in cases of severe impairment of renal function In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. Some renally-impaired or elderly patients being treated for hypertension may require a lower starting dose of atenolol: 25 mg given as one tablet a day. If this 25 mg dose is used, assessment of efficacy must be made carefully
The patient is currently on 25 mg of atenolol, which is a lower starting dose suitable for elderly patients 3. The patient's blood pressure is 140/62, which is a little high.
- The dosage of atenolol for hypertension can be increased to 50 mg or 100 mg daily if necessary, but caution is advised in elderly patients.
- Given the patient's age and current dosage, it is reasonable to monitor the patient's blood pressure and adjust the dosage as needed, rather than making any immediate changes.
- The patient's renal function should also be assessed to determine if any further adjustments to the atenolol dosage are necessary 3.
From the Research
Patient's Medication and Condition
- The patient is an 85-year-old female with new atrial fibrillation (AFib) and is currently on Eliquis (apixaban) and was initially started on Multaq but could not afford it, so she was left on atenolol 37.5 mg.
- The patient's atenolol dosage was reduced to 25 mg due to low heart rates shown on a Holter monitor.
- The patient is also on lisinopril 20 mg b.i.d. and has a blood pressure of 140/62.
Apixaban (Eliquis) Efficacy and Safety
- Studies have shown that apixaban is effective in reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation 4, 5.
- Apixaban has been compared to warfarin and rivaroxaban, and has been found to have a lower risk of major bleeding and intracranial hemorrhage 4, 5, 6.
- A subgroup analysis of the ARTESiA trial found that apixaban reduced the risk of stroke or systemic embolism in patients with subclinical atrial fibrillation and a history of stroke or transient ischemic attack 7.
Considerations for Patient's Treatment
- The patient's treatment with apixaban is consistent with the findings of the studies, which suggest that apixaban is a safe and effective option for patients with atrial fibrillation 4, 5, 6.
- The patient's blood pressure is a little high, but this is not directly related to the efficacy and safety of apixaban.
- The patient's reduction in atenolol dosage due to low heart rates is a separate consideration, and the patient's treatment with lisinopril 20 mg b.i.d. is not directly related to the efficacy and safety of apixaban.