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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Compare and contrast the risk factors for and the features, mechanisms, etiologies, symptoms, and goals of therapy of atrial fibrillation (AF)

  • Compare and contrast the mechanisms of action of drugs used for ventricular rate control, conversion to sinus rhythm, and maintenance of sinus rhythm in patients with AF, and explain the importance of anticoagulation for patients with AF

  • Design individualized drug therapy treatment plans for patients with AF

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PATIENT PRESENTATION

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Chief Complaint

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"I was supposed to come back if I didn't feel right."

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History of Present Illness

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Linda Leong is an 81-year-old Asian female who approximately 1 month ago presented to the emergency department with complaints of SOB, palpitations, fatigue, lightheadedness, and weakness of unspecified duration. She was found to be in AF with a ventricular rate of 130 bpm. At the time of admission, no atrial thrombus was present via transesophageal echocardiography (TEE). Diltiazem was initiated to control her ventricular rate with good response, and IV heparin for bridging plus long-term warfarin was initiated for stroke prevention. The decision for cardioversion was deferred at that time, and she was discharged on diltiazem, warfarin, and her other chronic medications. During the hospitalization, LL was also noted to have lower extremity edema and an elevated JVD, and she was treated with furosemide. She presents today in the cardiology clinic for follow-up. She states she has been compliant with her medications, still feels tired, and occasionally notices she has a fast heart rate.

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Past Medical History

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AF

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HTN

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Heart failure (HF) (EF 50% [0.50] 1 mo ago)

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Glaucoma

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Dementia

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Heartburn

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Family History

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Mother had CAD and died of an MI at age 66. Father died of lung cancer at age 81. She has one younger brother and sister who are healthy.

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Social History

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Married and lives with her husband of 47 years.

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Tobacco/Alcohol/Substance Use

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Occasional glass of wine with dinner; (−) tobacco or illicit drug use

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Allergies/Intolerances/Adverse Drug Events

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No known drug allergies

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Medications (Current)

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Diltiazem XR 240 mg PO once daily

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Warfarin 2.5 mg PO once daily

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Lisinopril 40 mg PO once daily

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Furosemide 20 mg PO once daily

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Donepezil 10 mg PO once daily

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Ranitidine 150 mg PO once daily

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Travoprost Z 0.004% one drop each eye once daily

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Multivitamin PO once daily

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Review of Systems

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Still reports fatigue over the last month since discharge from ...

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