Management of Anticoagulation in the Older Adult With AFib in the Context of CKD (Non End-Stage Renal Disease) | Patient Case Quiz
Patient Presentation Overview: A 76-year-old male presents to establish cardiac care from a neighboring state.
Positive Past Medical History: Diabetes mellitus type II, hypertension, hyperlipidemia, presumed transient ischemic attack, chronic kidney disease (CKD), and atrial fibrillation.
Medications (Name, Dose, and Frequency): Metoprolol succinate 100 mg daily, atorvastatin 40 mg daily, ASA 81 mg daily, and lisinopril 10 mg daily
Medication Allergies: None
Pertinent Social, Family History: He lives alone and is able to complete all of his activities of daily living without problems. He still drives short distances and recently moved to live with his adult children.
Review of Systems: He denies any falls in the past and does not use an assistive device for ambulation. He denies chest pain and dyspnea on exertion. He denies lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea. He denies any palpitations, syncope, or presyncope.
Blood Pressure: 135/80 mm Hg
Heart Rate: 90 bpm
Weight: 75 kg
Focused Physical Exam
General: Appears well, not distressed, well nourished
Neck: Supple, no visible jugular venous distension
Cardiovascular: Irregular S1 without murmur or gallop
Respiratory: Clear to auscultation bilaterally
Abdomen: Soft and non-tender to palpitation
Neurological: No focal deficient, can perform sit to stand without assistance
Extremities: Warm and well perfused, no edema or venous stasis changes
Pertinent Laboratory Data
Hemoglobin: 13 gm/dL
Creatinine: 2.0 (estimated glomerular filtration rate [eGFR] 32 ml/min/m2 by CKD-EPI equation)
Pertinent Cardiac Studies
Electrocardiogram (ECG): An ECG confirms atrial fibrillation with a ventricular rate of 90.
Transthoracic Echocardiography: Transthoracic echocardiogram shows a normal left ventricular ejection fraction and no regional dysfunction. There is left ventricular hypertrophy and marked left atrial enlargement. Filling pressures appear normal.
Additional Pertinent Comments: The patient and his family are unsure if he has ever been prescribed anticoagulants in the past and would prefer a medication that did not require frequent laboratory assessment.
Based on data derived from randomized trials, which dose among the following anticoagulant agents is NOT appropriate for stroke prevention among patients with CKD stage 3?