D.G. is a 74-year-old woman who arrives at the emergency room complaining of shortness of breath, palpitations (for 2 days), and lower extremity edema. Her medical history includes diabetes mellitus, hypertension, heart failure with reduced ejection fraction, and osteoarthritis. She had a left heart catheterization and coronary angiography last year and has no significant coronary artery disease. She has a biventricular pacemaker/implantable defibrillator for heart failure symptom treatment and sudden cardiac death prevention. The patient’s current medications are losartan 100 mg/d, metoprolol succinate 50 mg/d, metformin 500 mg twice daily, spironolactone 25 mg/d, furosemide 40 mg/d, and naproxen 500 mg twice daily.
Vital signs are as follows: blood pressure of 140/80 mm Hg, respiratory rate of 30 bpm, and heart rate of 120 bpm. ECG shows atrial fibrillation with a rapid ventricular response. Echocardiography reveals a moderately dilated left atrium, left ventricular systolic ejection fraction of 35% (unchanged), chronic kidney disease (baseline serum creatinine 1.01 mg/dL), and moderate mitral regurgitation.
Pertinent laboratory values include the following: hemoglobin 12 g/dL, hematocrit 36%, platelets 300,000/microliter, and serum creatinine 1.20 mg/dL (estimated creatinine clearance 39 mL/min). Her weight is 60 kg (increased from 55 kg), and height is 5 ft 3 inches. She does not smoke and does not drink alcohol. Dietary habits include one can of Ensure daily, with other meals provided by a social service agency (Meals on Wheels). Social concerns include the fact she lives alone, but a son visits every 1 to 2 weeks and transports her to physician appointments. She is living on a limited budget. With regard to her medication adherence, her son states that she occasionally forgets to take her afternoon medications, but overall, she is considered to be reasonably adherent with her drug regimens.
Diagnosis: Atrial fibrillation, acute onset
Answer the following questions. Include two references, cited in APA style.
- List specific goals of treatment for D.G.
- What drug therapy would you prescribe for stroke prevention in atrial fibrillation? Why?
- What are the parameters for monitoring success of the anticoagulant therapy?
- Discuss specific patient education based on the prescribed therapy.
- List one or two adverse reactions for the selected agent that would cause you to change therapy.
- What would be the choice for the second-line therapy?
- What OTC or alternative medications would be appropriate for D.G.?
- What lifestyle changes would you recommend to D.G.?
- Describe one or two drug–drug or drug–food interactions for the selected agent.