What is the next step for a 41-year-old male patient with atrial fibrillation (AFib) who underwent cardioversion and is currently on Eliquis (apixaban) and Multaq (dronedarone) 100 mg twice daily (b.i.d.), with a recent Holter monitor showing no signs of atrial fibrillation but some pauses, the longest being 3.7 seconds, during sleep hours?

From the Guidelines

The patient should continue to be monitored with a follow-up Holter monitor in 1-3 months to assess if the pauses persist or worsen, while maintaining the current anticoagulation with Eliquis and Multaq 100 mg twice daily. The recent Holter monitor showing pauses of up to 3.7 seconds during sleep hours in a patient with a history of atrial fibrillation who has been successfully converted to sinus rhythm after cardioversion, and is currently on Eliquis and Multaq, does not necessarily indicate an immediate need for intervention 1. According to the 2024 ESC guidelines for the management of atrial fibrillation, the primary indication for long-term rhythm control should be the reduction in AF-related symptoms and improvement in quality of life, and sinus rhythm maintenance can be pursued to reduce morbidity and mortality in selected patient groups 1. Key considerations in the management of this patient include:

• The patient's history of AFib and the importance of maintaining anticoagulation with Eliquis to prevent thromboembolism, as recommended by the guidelines for patients with a history of AFib 1.
• The use of Multaq (dronedarone) for rhythm control, which may contribute to increased vagal tone during sleep, potentially leading to nocturnal pauses 1.
• The need for ongoing monitoring to assess the persistence or worsening of pauses, as well as the development of symptoms such as dizziness, syncope, or extreme fatigue that might indicate symptomatic bradycardia while awake.
• The potential for dose adjustment of Multaq or evaluation for a pacemaker if future monitoring shows worsening pauses or the development of symptoms. Overall, the current management strategy should prioritize maintaining sinus rhythm, preventing thromboembolism, and monitoring for potential complications, with adjustments made as necessary based on ongoing assessment and patient symptoms 1.

From the FDA Drug Label

The majority of deaths in the dronedarone group were classified as arrhythmic/sudden deaths (HR, 3.26; CI: 1.06 to 10.0). MULTAQ is not for people with heart failure with symptoms which recently worsened or for people with severe heart failure. Do not take MULTAQ if you have symptoms of heart failure which recently worsened or if you have severe heart failure Call your doctor right away if you have any signs and symptoms of heart failure: shortness of breath or wheezing at rest MULTAQ may cause liver problems, including life-threatening liver failure.

The patient has been on Multaq 100 mg b.i.d. and Eliquis after cardioversion for AFib, and a recent Holter monitor showed no signs of AFib but some pauses during sleep hours. Given the information from the Multaq label, the patient should be monitored for signs and symptoms of heart failure and liver problems. The pauses during sleep hours may be a concern, but there is no direct information in the provided labels to guide the next steps. However, considering the patient's current medication regimen and the potential risks associated with Multaq, it is essential to closely monitor the patient's condition and consult with a physician to determine the best course of action 2.

From the Research

Patient Management

The patient in question is a 41-year-old male with a history of atrial fibrillation (AFib) who underwent cardioversion and has been on Eliquis and Multaq 100 mg b.i.d. since discharge. A recent Holter monitor showed no signs of AFib but revealed some pauses, with the longest being 3.7 seconds during sleep hours.

Assessment of Current Treatment

• The patient is currently on Eliquis (apixaban), a direct oral anticoagulant (DOAC), which is commonly used for stroke prevention in patients with non-valvular atrial fibrillation 3.
• The patient is also on Multaq (dronedarone), an antiarrhythmic drug used to treat irregular heartbeats 4.
• The combination of apixaban and dronedarone has been studied, and it was found that the bleeding risks were not significantly different from those of warfarin and dronedarone 4.

Holter Monitor Findings

• The Holter monitor showed no signs of AFib, which is a positive outcome considering the patient's history of AFib.
• However, the monitor did reveal some pauses, with the longest being 3.7 seconds during sleep hours. This finding may require further evaluation to determine its significance and potential impact on the patient's treatment plan 5.

Next Steps

• Continue to monitor the patient's heart rhythm to ensure that the AFib does not recur and to assess the significance of the pauses detected on the Holter monitor 6, 7.
• Consider adjusting the patient's treatment plan if necessary, based on the results of further monitoring and evaluation 3, 4.
• Evaluate the patient's overall cardiovascular risk and adjust the treatment plan accordingly, taking into account factors such as the patient's CHADS(2) score and other comorbidities 6, 7.