Management of Anticoagulation in the Older Adult Patient With AFib in the Context of CKD Stage 5 on Hemodialysis | Patient Case Quiz

Patient Presentation Overview: A 71-year-old female patient presents for ongoing cardiology follow-up care. Routine pacemaker interrogation prior to the appointment reveals several intermittent episodes of atrial fibrillation (AF) with each episode lasting more than 24 hours.

Pertinent Positive Medical History: Type 2 diabetes mellitus, hypertension, hyperlipidemia, obesity, peripheral arterial disease (PAD), chronic kidney disease (CKD) stage 5D secondary to diabetic nephropathy on dialysis for five years, remote syncope and complete heart block status post implantation of dual-chamber permanent pacemaker, prior lone episode of AF three years ago during critical illness status post-direct current cardioversion (DCCV) with no subsequent episodes until now.

Medications (Name, Dose, and Frequency): Carvedilol 25 mg bid, atorvastatin 40 mg daily, ASA 81 mg daily, and several supplements

Medication Allergies: None

Pertinent Social, Family History: The patient is Spanish-speaking. She lives with her adult daughter and attends an elder care program during the day. She does not smoke tobacco or drink alcohol. She has no known family history of cardiac disease but has very limited records of her family.

Review of Systems: She denies any recent syncopal episodes. She denies any falls, although she is nearly entirely wheelchair bound due to PAD and debility. She does not have chest pain or dyspnea but her exertion is significantly limited.


Height: 60 inches
Weight: 200 lbs
Body Mass Index: 39
Blood Pressure: 140/82 mm Hg (on an inter-dialysis day)
Heart Rate: 65 bpm
O2 Saturation: 96% on room air

Focused Physical Exam

General: Appears chronically ill
Neck: No jugular venous distention appreciable
Cardiovascular: Regular rate and rhythm, no murmur
Respiratory: Clear to auscultation bilaterally
Abdomen: Obese, soft and non-tender
Neurological: Intact grossly
Extremities: No edema, warm to touch, areas of open wound that are covered

Pertinent Laboratory Data

Hemoglobin: 11 gm/dl
Creatinine: 9.8 (on an inter-dialysis day)
Blood Urea Nitrogen: 40

Pertinent Cardiac Studies

Transthoracic Echocardiography: Left ventricular (LV) function is at lower limits of normal, and a possible new anterolateral regional wall motion abnormality is noted. No significant valvular disease is present. LV and right ventricular filling pressures were noted to be moderately elevated.

Which newer anticoagulant/dose combinations have FDA approval to mitigate the risk of stroke/systemic embolism due to paroxysmal AF in the context of CKD stage 5D?

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