Managing Anticoagulation in a Patient With Nonvalvular AFib on Hemodialysis

Apr 23, 2014   |  
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A 66-year-old male with end-stage renal failure is referred to the cardiovascular clinic for management of newly diagnosed paroxysmal atrial fibrillation (AF). A day prior to presentation he underwent hemodialysis and complained of palpitations. A 12-lead electrocardiogram (ECG) demonstrated AF at a rate of 100 beats per minute. After a few minutes, and without any intervention, the palpitations stopped and a second ECG demonstrated normal sinus rhythm. In retrospect, the patient reported that he had been experiencing intermittent palpitations during the last three months.

He has medical history of hypertension, hyperlipidemia, diabetes, and end-stage renal disease (on hemodialysis three times per week). In 2010 he experienced a deep vein thrombosis of the right lower extremity after a total knee replacement surgery. He was treated with warfarin for three months. During this time he had frequent bruising without trauma. His outpatient medications included lisinopril 5 mg daily, rosuvastatin 10 mg daily, aspirin 81 mg daily, insulin glargine 20 units at night, insulin aspart 7 units before meals, salbutamol inhaler as needed, and inhaled tiotropium 18 mcg daily. He does not have reported allergies.

On arrival to the cardiovascular clinic, he is asymptomatic. He is afebrile and has an irregular heart rate of 90 beats per minute, blood pressure of 140/75 mm Hg, respiratory rate of 14 breaths per minute, oxygen saturation of 95% on room air, and body weight of 180 pounds (81 kilograms). Physical exam is only remarkable for an irregular irregular rhythm. An ECG shows AF with a ventricular rate of 90 beats per minute. A transthoracic echocardiogram shows an ejection fraction of 55% with a moderately enlarged left atrium but no significant valvular abnormalities. The patient is reluctant to try warfarin again.

Which of the following medical interventions is the most appropriate to reduce the risk of stroke and systemic embolism in this patient?

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