Atrial Fibrillation Seminar Case 1

CC: “My chest seems to be pounding fast and it will not go away”

HPI: MJ is a 66-year-old Caucasian male who presents to his PCP because of increased chest palpitations. The patient stated that he started feeling chest palpitations about 2 weeks ago. At first he barely noticed them and attributed them to some bad heartburn from eating too much spicy food. However, the palpitations have become progressively more prominent over the last 4-5 days and therefore the patient thought he should visit the doctor. The patient states that he has had no recent medication changes and has been on the same medication regimen for about 2-3 years now. The patient also stated that he felt similar chest pounding about 4 months ago but it seemed to go away really quick and decided he did not need to do anything about it.

PMH: Meds:
DM Type 2 ASA 81 mg PO daily
HF (LVEF ~35%) (13 years ago) Furosemide 20 mg PO daily
HTN KCL 10 mEq PO daily s/p MI (16 years ago) Lisinopril 20 mg PO daily
Hypercholesterolemia Atorvastatin 40 mg PO daily
Gout Metoprolol succinate XL 25 mg PO daily Glipizide XL 20 mg PO daily Allopurinol 150 mg PO daily
Allergies: NKDA

SH: Lives with wife; employed as a construction foreman; quit drinking alcohol after HF diagnosis; quit tobacco after MI; tries to stay active and does moderate exercise at the gym at least 3 times/week. Plays golf every other weekend.

FH: non-contributory

Today’s PCP Visit:

ROS: Denies fever, chills, N/V, weight gain, fatigue or SOB (although admits to having some SOB with strenuous or heavy exercise; + chest palpitations
PE: BP 132/84 HR 140 RR 13 Temp 37.3 Ht 6’2” Wt 87 kg
Gen: A &O x 3; well-nourished male in no apparent distress
Lungs: CTA
CV: Irregularly irregular rhythm
Abdomen: Soft, NT, ND, +BS
Extremities: (-) edema

|139 |101 |12 |110 |13.2 |12 |232 |
| 3.8 |19 |1.1 | | |33 | |

INR 1.1, Mg 2.1, TSH (normal), LDL 102, QTc 424 msec

The physician’s assessment is consistent with a diagnosis of Atrial Fibrillation
Please complete the JCPP Concept Map based on today’s PCP visit and turn in for your homework activity.

Atrial Fibrillation Seminar Case 1 JCPP Concept Map

|Step 1: Knowledge of Disease(s)/Condition(s): |
| |
|Atrial Fibrillation: |
|Patient specific factors for AF: History of MI, HF diagnosed 13 years ago, history of HTN. |
|Chest palpitation 2 weeks ago means “persistent” AF. |
|Step 2: Review of General Goals of Therapy: |
|Controlling symptoms, increase quality of life. |
|Prevention of long-term complications |
|Thromboembolism |
|Cardiomyopathy |
|Arrhythmias |
| |
| |
|Step 3: Patient-Specific Factors: |Step 4: Medication History/Med Rec |Step 5: Refer to Evidence-based Medication |
|S: Chest palpitations 2 weeks ago, happened 4 | |Guidelines: |
|months ago, SOB with strenuous exercise |Current RX Medications: | |
| |ASA 81 mg PO daily |Refer to 2014 AHA/ACC/HRS for Atrial Fibrillation |
|O: HR: 140 (tachycardia), BP: 132/84, Irregularly |Furosemide 20 mg PO daily |Guidelines. |
|irregular heart rhythm, qtc 424 sec, TSH is normal,|KCL 10 mEq PO daily |Refer to JNC8 for Hypertension Guidelines. |
|INR: 1.1 |Lisinopril 20 mg PO daily |Refer to ACC/AHA for Hyperlipidemia Guidelines |
| |Atorvastatin 40 mg PO daily |Refer to ADA for Diabetes Guidelines |
|PMH: HF (13 years, LVEF 35%), s/p MI, DM Type 2, |Metoprolol succinate XL 25 mg PO daily |Refer to ACC/AHA/HFSA for HF Guidelines |
|HTN |Glipizide XL 20 mg PO daily | |
| |Allopurinol 150 mg PO daily | |
|SH: quit drinking alcohol after HF diagnosis; quit | | |
|tobacco after MI; tries to stay active and does |OTC/Herbals/Vitamins: | |
|moderate exercise at the gym at least 3 times/week.|Information not available | |
|Plays golf every other weekend. | | |
| |Alternative Medications (CAM): | |
| |Information not available | |
|FH: N/A | | |
| |Drug Allergies: NKDA | |
|Non-drug allergies: N/A | | |
|Step 6: Preliminary Assessment (one liner on the patient): |
|MJ is a 66-year-old white male who presents to his PCP with chest palpitation that have been worsening for 2 weeks, based on his signs and symptoms as well |
|as his lab results, MJ may be showing signs of persistent Atrial Fibrillation and would benefit from pharmacotherapy to improve quality of life and decrease|
|long term complications of cardiomyopathy and arrhythmias. |
|Step 7A: Set Evidence Based Patient-Specific Goals:|Step 7B: Problems |Step 7C: Assess Therapy |
| |DRPs: | |
| |Clinical Indication but no Therapy (Atrial |Atrial Fibrillation: |
|Atrial Fibrillation: |Fibrillation) | |
|Does the patient need rate control? |Patient Education on Atrial Fibrillation |Beta Blockers: Indicated for rate control because |
|Yes, patient is stable (with no hypotension, SOB, |Drug Underdose on Metoprolol |they block sympathetic tone, lengthens |
|or syncope) but symptomatic with chest palpitations|Drug Underdose on Anti-coagulation (ASA 81mg) |refractoriness, decreases conduction velocity, and |
| | |decreases automaticity in nodal tissue. Avoid use |
| | |in decompensated acute HF. Decreases mortality by |
|Does the patient need rhythm control therapy? | |decreasing remodeling of the heart. Side effects |
|No, Patient is stable (with no hypotension, SOB, or| |include bradycardia, hypotension. Patient is not on|
|syncope) but symptomatic; no need for rhythm | |recommended dose for AF. |
|control at this time | | |
| | |Digoxin: Indicated for rate control but not as |
|Does the patient need anticoagulation? | |first line option, its vagotonic actions result in |
|Yes, CHA2DS2-VASc score is 5 so oral | |calcium current inhibition in AV node, activation |
|anticoagulation is a Class 1 Recommendation if no | |of acetylcholine-mediated potassium currents in |
|apparent bleeding risk is present. | |atrium, lengthens refractoriness, and decreases |
| | |impulse conduction. Can be useful in HF patients |
|Hypertension: Per JNC8 guidelines since patient has| |and can be used in combination with BB. Been |
|diabetes, BP goal is <140/90. | |associated with increased mortality. Many drug |
| | |interactions. |
|Hyperlipidemia: Per ACC/AHA guidelines patient | | |
|should be on high intensity statin because they | |Amiodarone: Not indicated as first line for AF, |
|have a clinical ASCVD event. | |useful in decompensated HF with low EF as well as |
| | |patients with contraindications to other |
|Diabetes: Per ADA Guidelines, fasting blood glucose| |medications |
|level’s target goal is 80-130 mg/dl and a1c is less| | |
|than 7%. | |Non-DHP CCB: Indicated for rate control, blocks |
| | |L-type calcium channels, lengthens refractoriness, |
| | |decreases conduction velocity, and decreased |
| | |automaticity in nodal tissue. Avoid in |
| | |decompensated HF as well as low EF. |
| | | |
| | |Hypertension: Blood pressure is at goal of less |
| | |than 140/9, continue current therapy of Lisinopril |
| | |20mg |
| | | |
| | |Hyperlipidemia: Patient is currently on indicated |
| | |therapy of high intensity statin. Continue on |
| | |Atorvastatin 40mg. |
| | | |
| | |Diabetes: Patient’s blood glucose is at target goa,|
| | |continue current therapy of Glipizide XL 20mg. |
| | | |
| | | |
|Step 8: Assessment (one or two liner) |
|Is the patient Stable or Unstable? |
|Stable, persistent atrial fibrillation. |
|How long has the patient been in A-fib? |
|Patient has chest palpitations for 2 weeks but has been experiencing symptoms 4 months ago. |
|Step 9: Implement Action Plan (Problem List with Plan) |
|Recommend increase Metoprolol Succinate dose up to 50mg PO daily. |
|Recommend start Warfarin 5mg for anti-coagulation |
|Step 10: Outcome Assessment and Monitoring Plan: |
|Atrial Fibrillation: monitor for HR, BP, chest palpitations, SOB |
|Anti – coagulation: monitor for INR every week (goal of 2-3), bleeding, CBC |
|Hypertension: monitor for blood pressure, dry cough, edema, potassium levels |
|Hyperlipidemia: monitor lipid panel, myalgia, muscle aches |
|Diabetes: Monitor a1c and blood glucose levels |
| |
| |
|Self-Care Monitoring Plan: |
|Continue exercising 30 min for at least 5 times a week |
|Restrict salty foods, utilize DASH diet. |
|Watch weight and fluid gains. |
| |
|Follow up in 6 weeks with PCP. |
| |
|Signed: |
|Jonathan Chen 4th year Pharmacy Student |

Atrial Fibrillation Seminar Case 2

SB is a 67-year-old male admitted to the ICU for pneumonia and is now found to be in atrial fibrillation. The patient is stable but the ICU attending wants the patient chemically cardioverted. The first-year ICU resident was told by the attending to start IV amiodarone followed by oral amiodarone (when appropriate) in order to chemically cardiovert the patient. However, the resident is not that familiar with the drug and would like you (the pharmacist) to educate her regarding the side effects and drug interactions of the medication and when to monitor for the toxicities of the drug.

In the table below, please list and discuss the specific adverse effects for each of the body systems listed and the timeframe in which to monitor for the adverse effects associated with each body system.

|Body System |Adverse effects / Monitoring timeframe |
|Cardiovascular | |
|Neurologic | |
|Dermatologic | |
|Endocrine | |
|Opthalmologic | |
|Pulmonary | |
|Hepatic | |
|GI disturbances | |

Please inform the resident regarding the pertinent amiodarone drug interactions in the box below

(Note: just looking for basic drug interaction information—feel free to elaborate. The interactions in the box were discussed in lecture)

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