Fast AF in failure secondary to unstable angina

1. Ward case
Fast Atrial Fibrillation in Failure
Secondary to Unstable Angina
Ward: 8CD
Presented by: Khairunnisa Zamri
Preceptor: Pn. Norsima Nazifah Sidek

2. What is Atrial Fibrillation (AF)?
 Atrial fibrillation (AF): is an atrial tachyarrhythmia
characterized by uncoordinated atrial activation with
consequent deterioration of atrial mechanical function 1
 More common causes: ischaemic heart disease,
hypertensive heart disease, rheumatic heart disease,
thyrotoxicosis, post-surgery, chronic lung disease, atrial
septal defects and acute alcohol intoxication.
CPG on Management of Atrial Fibrillation (2012)

3. Classification of AF
Adapted from the ESC Guidelines for the Management of Atrial Fibrillation (2010 version)
(European heart Journal 2010; doi: 10.1093/eurheartj/ehq278)

4. Symptoms and general treatment
Symptoms: palpitation, dyspnoea, angina in suspectible individuals, hypotension,
syncope, fatigue, heart failure, pulmonary oedema.
•Treatment: general principles
Rhythm control-reversion to normal sinus rhythm (NSR) followed by
maintenance of NSR
Rate control-administration of medications to control the ventricular rate
Prevention of systemic thromboembolism with anticoagulation (or
antiplatelet in selected patients).
Choice of the treatment will depend on the clinical presentation and whether
the AF is paroxysmal, persistent or permanent

5. Patient’s name MM
R/N 169547
Age 73 years old
Gender Female
Race Malay
Ward 8c
Date of admission 8/04/2014
DEMOGRAPHIC DATA

6. Chief complaint 8/4/14 -Arived at ED with chest pain
radiated to neck and left arm
-pain score: 7/10
-having on and off shortness of
breath, chest tightness
Past Medical History: 1. Cerebrovascular accident (CVA) in
2006-has residual right hemiparesis
2. Hypertension- since 2005, follow up
at Klinik Kesihatan Ketengah Jaya
3. Ischemic heart disease (IHD)-
undecided register COROS.
-has history of admission last September
for fast AF secondary to ACS reverted
with amiodarone.
-planned for angiogram, undecided and
patient defaulted follow-up.
-ECHO was done in Sept 2013: EF 66%,
good left ventricular systolic function,
chamber normal size and no
clot/thrombus.

7. Social/Family Hx: Premorbidly ADL independent,
walking with aid.
Past medication Hx: -Tab.trimetazidine 20mgTDS
-Tab.simvastatin 20mg ON
-Tab.aspirin 150mg OD
-Tab.clopidogrel 75mg OD
-Tab.bisoprolol 2.5mg OD
-Tab.neurobion I/I OD
-Tab.perindopril 2mg OD
On examination: -pink, not tachypnoeic, bilateral pedal edema
-Pulse rate: 170-180 bpm
-Blood pressure: 148/123 mmHg
Temperature: 37 °C
dscan: 6.5 mmol/L
1)ECG at 10am (8/4/2104), fast AF with
ischemic changes, pulse rate 170-180,
ST elevation lead II, III, avF.
2)ECG at 10.30am: fast AF, ST depression at
v2-v6.
Chest X-ray: overload features-to strict I/O
chart
-IV digoxin 0.25mg stat
-Tab. Clopidogrel 75mg stat
-Tab.Aspirin 300mg stat
- IV amiodarone 300mg in 50ml
D5%, run over 1 hour.
-IV frusemide 50mg stat

8. Diagnosis/Surgical
procedure
1)FastAF in failure secondary to
unstable angina
2) Acute on CKD

9. Lab investigation
Full Blood Count
Renal profile
Higher than normal range Lower than normal range
Blood
count
TWBC
[5.2-12.4]
RBC
[4.7-6.1]
Hb
[14-
18]
Hct
[42-52]
Plt [150-
400]
13/04/14 6.8 3.71 13.0 44.5 212
Urea[2.5-
7.4]
Na [136-145] K [3.5-5.0] SCr
[53-115]
CrCI
(ml/min)
8/04/14 10.7 142 3.4 134 19
13/04/14 15.4 140 3.3 309 8
*not for fondaparinux in view of CrCI less than 30ml/min

10. Lipid Profile
Cardiac enzymes
CK[<145 ] LDH[<248] AST
[>37]
8/04/14 66 272 32
T.chol
[<5.7]
TG
[<1.7]
HDL
[>1.7]
LDL[<3.9]
8/04/14 6.0 0.8 1.4 4.2

11. Date Progress Plan
08/04/2014
AtWard 8C
Chest X-ray: overload
features
Had bilateral pedal edema
Bisoprolol was withold and
IV frusemide 40mg BD was
started.
Strict I/O chart, aim
negative balance
For fluid restriction
800cc/24 hour
Other old medications
were continued.
On examination:
BP 148/123 mmHg
125/90 mmHg and PR from
180-170 bpm to128 bpm.
For IV amiodarone 900 mg
in D5% for 23hr.
For IV heparin bolus 2400
units (60 unit/kg), followed
by continuous infusion
(12unit/kg/hr) for 48 hours
and to aim aPTT 57.9-96.5.
For 6-hourly PTTK/INR.
If HR < 70 bpm or BP <
90/60 mmHg, KIV to off IV
amiodarone

12. Date Progress Plan
09/04/2014 On examination
BP: 147/83
PR: 75
T: 37°C
On IV amiodarone maintenance
900mg in 50cc D5% for 23 hr.
On IV heparin with 6-hourly
PTTK/INR
Still having chest pain but
improving
No shortness of breath, nausea
and vomiting, headache.
-Continue IV amiodarone
maintenance (complete for
23 hrs) and IV heparin
(complete for 48 hrs).
-For lifelong warfarin and to
discuss with family members
regarding this matter once IV
heparin completed (patient
strongly refused warfarin
therapy due to logistic and
social reason).
On examination
BP: 172/76 mmHg
PR: 80
T:37
-Continue the previous plan.
KIV for beta-blocker/digoxin
if BP is not controlled.
-No need warfarin at the
moment, since it is not
indicated in AF induced by
ACS.
To re-start bisoprolol 2.5mg
OD

13. Date Progress Plan
9/04/2014 APTT (activated partial
thromboplastin time) >120
seconds (normal range: 29-40).
Withold IV heparin for 30
minutes
Reduce infusion by 1unit/kh/hr
For next APTT at 7pm.
To repeat ECG
10/04/2014 Patient claimed having cough
when started with ACEI
previously.
On examination:
BP: 122/76 mmHg
PR: 84 bpm (good pulse
volume)
RR: 20 bpm
Latest APTT at 7pm: 57.1
ECG: sinus rhythm, HR 60
bpm. No evolving changes
Discontinue perindopril and
start with Tab. losartan 50mg
OD
To complete IV heparin by 12
midnight today.
Dabigatran 110mg BD was
started.

14. Date Progress Plan
11/04/2014 Completed IV amiodarone
maintenance at 12 midnight
(10/04/14).
Complained of constipation,no bowel
output since admission (3 days ago).
No chest pain, shortness of breath,
headache.
On examination:
BP: 137/65
PR: 70 bpm
RR: 22
T: 37°C
ECG: sinus tachycardia
-Off dabigatran in view of her serum
creatinine < 30ml/min (19 ml/min, on
8/04/14).
-Off heparin infusion.
-Syrup lactulose 15ml ON was given
for her constipation.
-T. bisoprolol 2.5mg OD was re-
started.
-IV frusemide was reduced from 40mg
BD to OD since patient’s edema was
improving.
13/04/2014 Her oral intake improved.
BP: 140/80 mmHg
HR: 80bpm
Lungs clear
-IV frusemide was changed toT.
frusemide 40mg OD.
-Patient allowed to be discharged after
being reviewed by cardiology team.
-Her condition improved and patient
was given Holter appointment at
MOPD on 6/05/2014.
According to cardiology team, there
was no need for warfarin at the
moment as it was not indicated in AF
induced by ACS.The same applies to
anticoagulation by dabigatran.The use
of dabigatran in valvular lesion might
do more harm than good

15. ASSESSMENT OF THERAPY
Medications given Date Indication/rationale
1.IV Amiodarone 300mg in
50ml D5%, run for 1 hr
-continue with the
maintenance IV
amiodarone 900mg in
50ml D5% run for 23 hr
8/4-10/4/14 -as AF pharmacologic
cardioversion
2. IV heparin 2400 units (60
unit/kg) ), followed by
continuous infusion
(12unit/kg/hr) for 48 hours
8/04/14-10/4/14 -as anticoagulant therapy to
prevent systemic embolization
3. Tab. Potassium chloride 1.2g
OD
8/4/14 -as potassium supplement to
prevent further hypokalemia
4.Tab. perindopril 2mg OD 8/4/14-9/4/14
*discontinue since patient
complained of having cough
when started with ACEI
previously
-for hypertension management
5.Tab. losartan 50mg OD 9/4/14-continue as discharge
medication
-as alternative to ACEI in
patient who cannot tolerate
with side effects of ACEI (dry
cough)

16. Medications given Date Indication/rationale
7.Tab. Simvastatin 20mg ON 8/4-continue as discharge
medication
-as lipid-lowering agent in ACS
management
8.Tab.Aspirin 150mg OD 8/04/14-continue as discharge
medication
-as dual antiplatelet therapy in
ACS management
9.Tab. Clopidogrel 75mg OD
10.Tab. Neurobion (Vit B1, B6
and B12)
8/4/14 -as treatment/prevention of
peripheral neuropathy
11.Tab.Trimetazidine 20mg
TDS
8/4/14-continue as discharge
medication
-as metabolic agent in ACS
management
12. IV Frusemide 40mg BD 8/4/14-change to Tab
Frusemide 40mg OD in view
of oral intake improved
-as treatment of pedal edema
13. IV Ranitidine 50mg TDS 8/4/14 -for stress ulcer prophylaxis
14.Tab. Dabigatran 110mg OD 10/04/14-discontinue in view
of patient’s CrCI <30ml/min
-to prevent stroke and
systemic embolism

17. Pharmaceutical care issues (PCI)
Date Issues Pharmacist’s
recommendation
Outcome of
treatment/monitoring
parameters
9/04//14 1.Patient has fast
AF in failure
secondary to
unstable angina
CHADs score: 6
HAS-BLED score: 4
To start warfarin as
antithrombotic therapy in AF.
-risk of stroke appears to be
similar in paroxysmal and chronic
AF (Sarawak Handbook, 3rd
edition).
-patient with paroxysmal AF
should be regarded as having a
stroke risk similar to those with
persistent or permanent AF, in the
presence of risk stroke (Clinical
Practice Guidelines on AF, 2012).
-However, according to
cardiology team, no need
for warfarin at the moment
as it is not indicated in AF
induced by ACS.
-Thus, our recommendation
was not accepted.

18. Patient’s stroke risk scores-CHA2DS2-VASc
Risk Criteria:

19. Date Issues Pharmacist’s recommendation Outcome of
treatment/monitoring
parameters
10/04//14 2. Patient
complained of having
cough previously
(might be due to
perindopril).
Patient was not able to
tolerate with side effect
of perindopril-dry cough
Disontinued perindopril and started
with Tab losartan 50mg OD.
-Losartan is an ARB (angiotensin
receptor blocker) that blocks
specifically angiotensin II receptor.
Unlike ACEIs, persistent dry cough is
less a problem and recommended in
ACEI intolerance patients
(CPG Management of Hypertension,
3rd edition).
Recommendation was
accepted but need to review
patient’s blood pressure if it is
well-controlled with only one
anti-hypertensive drug and
any side effects related to
ARB.
Upon discharged, her BP was
140/80 mmHg
13/04/14 3. Incomplete lab
data, not perform
LFT (liver function
test).
-Patient has started
statin as her previous
medication and her last
LFT done in September
2013)
-To perform liver function test (ALT
level) and monitor level within 1-3
months, discontinue if level rise 3
times upper limit of normal.
- To monitor muscle symptoms or
fatigue (rhabdomyolysis)-if suspected
measure CK level. Level more than
10 times the upper limit of normal
should discontinue.
(CPG on Management of
Dyslipidemia, 2011)
Her LFT test will be
performed on the next
appointment and reviewed
later.

20. Date Issues Pharmacist’s
recommendation
Outcome of
treatment/monitoring
parameters
13/04//1
4
4. High LDL level
withTab
simvastatin 20mg
ON
Patient’s lipid profile
revealed on 8/04/14
with LDL level was 4.2
mmol/L.
Patient has CHD and
CVA, whereby LDL
level should be
targeted <1.8 mmol/L
(Management of
Dyslipidemia, 2011).
-Changed Tab simvastatin
20mg to Tab atorvastatin
20mg.
-Based on statin conversion
guide, 20mg of simvastatin can
reduce 31-39% of LDL
equivalent to 10mg of
atorvastatin.
However, dose of 40mg
simvastatin can cause 37-45%
LDL reduction equivalent to
20mg of atorvastatin. Thus,
atorvastatin 20mg is preferable
in terms of easy of
administration and compliance
issue (patient has to take 1 tab
compared to 2 tab for
simvastatin), as well as cost-
effectiveness.
Intervention was not
conducted and patient
was discharged with Tab.
Simvastatin 20mg ON.

21. DISCHARGE MEDICATIONS
 Tab frusemide 40mg OD x 1/12
 Tab trimetazidine 20mgTDS x 1/12
 Tab aspirin 150mg OD x 1/12
 Tab clopidogrel 75mg OD x 1/12
 Tab simvastatin 20mg ON x 1/12
 Tab isosorbide dinitrate 10mgTDS x 1/12
 S/L glyceryl trinitrate (GTN) x 1/12
 Tab losartan 50mg OD x 1/12

22. COUNSELLING POINTS
 Cardivascular
 Medications
 Target BP and complications of high BP
 Salt and fluid restriction
 Indication, administration, storage, expiry and side effects
of S/L GTN
 Advise patient to bring S/L GTN all the time.

23.  Hyperlipidemia
 Medications
 Target cholesterol, HDL, LDL,TG
 Risk factor for hyperlipidemia:
diet in high saturated fat, excessive calories (eg: coconut milk, chicken
skin), obesity, lack of exercise
 complications: cardiovascular disease (Stroke, heart attack)
 indication of statin drug in reducing LDL level and increase HDL
 Mechanism of action of statin: to inhibit cholesterol production from
the liver
 Advice patient to take statin at night before sleep (more effective as
the liver produces more cholesterol in the middle of night, during
fasting state).
 Side effects of statin: myopathy, athralgia

24.  Healthy lifestyles
 Low salt diet (for HPT)
 Low fat diet (hyperlipidemia)
 Low potassium diet
 Exercise or doing suitable physical activities like brisk walking
 To advice patient take medicatios at the right time and have a
good compliance.
 To advise patient to avoid nephrotoxic drugs such as NSAIDs,
unregistered traditional medicines/herbs.To inform health care
providers if plan to take supplements or OTC products (since
she has renal impairment and need to monitor her renal
function in the coming follow-up).

25. References
1. CPG on Management of Chronic Kidney Disease in Adults (June 2011)
2. CPG on Management of Hypertension (February 2008)
3. CPG on Management of Atrial Fibrillation (2012)
4. CPG on Management of Dyslipidemia (2011)
5. Sarawak Handbook of Medical Emergencies, 3rd Edition.

26. Thank you 