Vignette: History of Present Illness: A 65-year-old man is being seen in the clinic for nonvalvular atrial fibrillation (NAF). He worked as a high school math teacher for 25 years but retired 6 months ago. He has been symptomatic with palpitations in the past but has had no symptoms in the past month.
Medical History: Hypertension, hyperlipidemia
Social History: Married, heterosexual male. Does not drink, smoke, or use recreational drugs
Current Medications: Lisinopril 20 mg orally daily, atorvastatin 40 mg orally daily
Allergies: Peanuts – anaphylaxis; sulfa antibiotics – rash
Vital Signs: Blood pressure 132/78 mm Hg, heart rate 74 beats/minute, respiratory rate 15 breaths/minute, Ht 74 inches (188 cm), Wt 230 lb (104.5 kg)
Laboratory Values: Serum chemistries, CBC, liver panel, and thyroid panel all within normal limits. Urine drug screen is negative.
Procedure Data: Not applicable
Other Data: Vaccine history: Influenza vaccination September 2019; Td booster 2015; reports no other vaccines in the past 5 years
Question 1: What is this patient’s CHA2DS2-VASc score?
1. 1
2. 2
3. 3
4. 4
Answer: 2. 2
Rationale: The patient has a history of hypertension and is 65 years of age, earning 1 point for each. He is not noted to have congestive heart failure, age older than 75, diabetes mellitus, stroke or transient ischemic attack, thromboembolism, vascular disease, or female sex category.
Citation: January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2019 Jan 28. pii: S1547-527130037-2.
Question 2: The patient comes to the pharmacy to refill his medications and receive updated vaccinations. Which vaccine is indicated for this patient?
1. M-M-R II
2. Pneumovax
3. Zostavax
4. Varivax
Answer: 2. Pneumovax
Rationale: Given the patient’s age (65), Pneumovax is recommended. In June, the ACIP guidelines were updated to state that PCV13 (Prevnar) is no longer recommended for patients 65 or older on the basis of “shared clinical decision-making” if patients have not already received the PCV13 vaccine. M-M-R II and Varivax are not indicated at this time. Shingrix is preferred to Zostavax for the prevention of herpes zoster and related complications in patients older than 50.
Citations: Centers for Disease Control and Prevention (CDC). Immunization Schedules. Table 1. Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States, 2020. Available at https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo. Accessed December 23, 2020.
Centers for Disease Control and Prevention (CDC). ACIP Recommendations. Available at https://www.cdc.gov/vaccines/acip/recommendations.html. Accessed December 23, 2020.
Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for use of herpes zoster vaccines. MMWR Morb Mortal Wkly Rep 2018;67:103-8.
Question 3: The patient will be initiated on a direct oral anticoagulant for NAF. Which recommendation is best for this patient?
1. Apixaban 5 mg twice daily
2. Dabigatran 75 mg twice daily
3. Edoxaban 30 mg daily
4. Rivaroxaban 15 mg twice daily for 21 days; then 20 mg daily
Answer: 1. Apixaban 5 mg twice daily
Rationale: The recommended starting dose of apixaban in patients with NAF is 5 mg twice daily. The dose should be decreased to 2.5 mg twice daily for patients who are 80 and older, whose body weight is 60 kg or less, or whose serum creatinine is 1.5 mg/dL or greater; however, this patient does not meet the criteria for a dose reduction. Because the patient’s creatinine clearance is normal, no dose reduction of dabigatran or edoxaban is needed; the agents should be dosed at 150 mg twice daily and 60 mg daily, respectively. The rivaroxaban dose listed is the regimen for an active deep venous thrombosis; the rivaroxaban dose should be 20 mg daily for this patient.
Citation: Eliquis® (apixaban) [package insert]. New York: Pfizer, 2016.
Question 4: After assessing the cost of direct oral anticoagulant therapy, the patient decides to try warfarin for NAF. Which is the most appropriate approach to transitioning from apixaban to warfarin?
1. Discontinue apixaban and initiate warfarin at the next scheduled dose.
2. Discontinue apixaban and initiate warfarin after 48 hours.
3. Discontinue apixaban, initiate enoxaparin and warfarin at the next scheduled dose, and discontinue enoxaparin when the INR is therapeutic.
4. Continue apixaban, initiate warfarin now, and discontinue apixaban when the INR is therapeutic.
Answer: 3. Discontinue apixaban, initiate enoxaparin and warfarin at the next scheduled dose, and discontinue enoxaparin when the INR is therapeutic.
Rationale: According to the package insert, when changing from apixaban to warfarin, apixaban should be discontinued, and warfarin with a parenteral low-molecular-weight heparin (LMWH) should be initiated at the next scheduled dose; the parenteral LMWH should then be discontinued when the INR is at target range. Options 1, 2, and 4 are not recommended by the package insert.
Citation: Eliquis® (apixaban) [package insert]. New York: Pfizer, 2016.
Question 5: Six months later, the patient is experiencing chest pain and must undergo a percutaneous coronary intervention (PCI) with stenting. The patient will be initiated on triple therapy with warfarin, aspirin, and a third agent. Which agent is preferred in this patient?
1. Clopidogrel
2. Prasugrel
3. Ticagrelor
4. Ticlopidine
Answer: 1. Clopidogrel
Rationale: For patients who have undergone PCI with stenting, clopidogrel is preferred for triple therapy.
Citation: January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2019 Jan 28. pii: S1547-5271(19)30037-2.