Panel Discussion: Challenging Cases in Practice
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Video Transcription
0:00
Okay, so now we're going to hark back to the cases that we had in the beginning, think about them now in the context of the lectures, and have our panel come in with opinions.
0:15
And while the questions mostly had a one best answer, I'll tell you at the front, they were also meant to spark thinking.
0:23
As we practice medicine, it's an art, there isn't always necessarily one best answer. So case one, this was the 65-year-old woman presented for clinic, past medical history,
0:39
persistent AFib on rivaroxaban with hypertension, diabetes, and sleep apnea. She had been having increased dyspnea on evening walks.
0:48
She had an exercise nuclear stress testing showing a reversible apical ischemia, as you can see here.
0:54
Her medical therapy was up titrated, she underwent cath as she still had symptoms. She got a drug eluting stent to the mid-LAD, she was placed on clopidogrel.
1:05
On exam, she was comfortable uvolemic, radial arterial site well healed, hemoglobin is 12, creatinine 0.8, GFR 60.
1:14
Due to the following was the best anticoagulation plan in the setting of her clopidogrel use, she has persistent atrial fibrillation, and the correct answer we were looking for was
1:24
rivaroxaban 15 milligrams daily with dinner. So again, she's on clopidogrel, so we're having dual therapy, and that harks back to the pioneer
1:34
AF study using rivaroxaban at the 15 milligram dose. So again, thinking about what is the correct dose, as Dr. Tracy alluded to, and Dr. Kumbani's
1:46
talk on how to correctly manage antithrombotic therapy after stenting. So I'm going to move on to the next one.
1:57
So now this patient develops heart failure, HFPEF, over the next several years. Hospitalized for heart failure three times in the past year.
Video Summary
The panel discussed several cases related to the management of atrial fibrillation (AFib). In case 1, a 65-year-old woman with persistent AFib and other medical conditions presented with increased dyspnea. The panel recommended rivaroxaban 15 mg daily with dinner as the best anticoagulation plan in the setting of her clopidogrel use. Case 2 involved a patient on dialysis who had a stroke while on warfarin with subtherapeutic INR. The panel recommended apixaban 2.5 mg twice daily as the appropriate anticoagulation strategy. Case 3 featured a patient with AFib who underwent stenting. The panel recommended continuing clopidogrel and apixaban indefinitely, with the possibility of de-escalation after one year. Case 4 involved a patient with a prior history of intracranial hemorrhage. The panel recommended left atrial appendage occlusion as the best next step. The discussion also touched on the use of catheter ablation and antithrombotic therapy after Watchman implantation.
Keywords
atrial fibrillation
anticoagulation plan
clopidogrel
stroke
warfarin
stenting
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