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Base it on CHA₂DS₂-VASc, not the rhythm pattern. For this patient the score is 4, a stroke risk high enough that a direct oral anticoagulant is preferred over warfarin.CirculationAHACirculationPractice Guideline2023 ACC/AHA/ACCP/HRS Guideline for the Management of Atrial FibrillationI·AClass ILOE AACC/AHAIn patients with AF and elevated stroke risk, oral anticoagulation is recommended; a DOAC is preferred over warfarin in eligible patients. 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline
- A DOAC is preferred over warfarin for nonvalvular AF.
CirculationAHACirculationPractice Guideline2023 ACC/AHA/ACCP/HRS Guideline for the Management of Atrial FibrillationI·AClass ILOE AACC/AHAIn patients with AF and elevated stroke risk, oral anticoagulation is recommended; a DOAC is preferred over warfarin in eligible patients. 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline
- Paroxysmal AF carries a stroke risk similar to persistent AF.
Eur Heart JESCEuropean Heart JournalPractice Guideline2024 ESC Guidelines for the management of atrial fibrillationI·AClass ILOE AACC/AHAIn patients with AF and elevated stroke risk, oral anticoagulation is recommended; a DOAC is preferred over warfarin in eligible patients. 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline
Anticoagulate at CHA₂DS₂-VASc ≥2 (men) or ≥3 (women); prefer a DOAC over warfarin for nonvalvular AF.
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H&P
History of Present Illness
72-year-old with hypertension, type 2 diabetes, and hyperlipidemia, admitted from the ED with new-onset atrial fibrillation and rapid ventricular response to 138. Two days of intermittent palpitations and brief exertional dyspnea, worse overnight. Denies chest pain, pressure, syncope, presyncope, fever, or recent illness. No prior arrhythmia; last echocardiogram normal.
Past Medical History
- Hypertension
- Type 2 diabetes mellitus (A1c 7.4%)
- Hyperlipidemia
- Chronic kidney disease, stage 2
- Obstructive sleep apnea, on CPAP
- Osteoarthritis
Home Medications
- Lisinopril 20 mg daily
- Metformin 1000 mg twice daily
- Atorvastatin 40 mg nightly
- Hydrochlorothiazide 25 mg daily
- Aspirin 81 mg daily
Allergies
Penicillin (rash).
Social History
Former smoker, 15 pack-years, quit 10 years ago. Occasional alcohol. Lives with spouse; independent in all activities of daily living.
Family History
Father with coronary artery disease; mother with ischemic stroke.
Review of Systems
Constitutional: No fever, chills, or unintentional weight loss.
Cardiovascular: Positive for palpitations; no chest pain, orthopnea, or PND.
Respiratory: Mild exertional dyspnea; no cough, wheeze, or hemoptysis.
Gastrointestinal: No nausea, vomiting, abdominal pain, or melena.
Genitourinary: No dysuria, frequency, or hematuria.
Neurologic: No focal weakness, numbness, headache, or visual change.
Endocrine: No heat or cold intolerance, polyuria, or polydipsia.
Physical Examination
Vitals: BP 138/86, HR 86 (rate-controlled), RR 16, SpO₂ 97% on room air, T 36.8 °C.
General: Well-appearing, comfortable, in no acute distress.
HEENT: Normocephalic, atraumatic; moist mucous membranes; no JVD.
Cardiovascular: Irregularly irregular rhythm; normal S1/S2; no murmurs, rubs, or gallops.
Pulmonary: Clear to auscultation bilaterally; no wheezes, rales, or rhonchi.
Abdomen: Soft, non-tender, non-distended; normoactive bowel sounds.
Extremities: Warm and well-perfused; no peripheral edema or calf tenderness.
Neurologic: Alert and oriented ×3; no focal motor or sensory deficits.
Studies & Data
ECG: Atrial fibrillation with RVR; no acute ST-segment changes.
Labs: Na 139, K 4.2, Cr 1.1 (baseline), Mg 1.9; troponin negative ×2; TSH pending.
Imaging: Chest radiograph without acute cardiopulmonary process.
Assessment & Plan
72-year-old with new-onset atrial fibrillation and rapid ventricular response, now rate-controlled and hemodynamically stable, on a background of hypertension and type 2 diabetes.
- Start apixaban 5 mg PO twice daily for stroke prevention (CHA₂DS₂-VASc 4).
- Rate control with metoprolol tartrate 25 mg PO twice daily; titrate to HR <110.
- Defer cardioversion; rate-control strategy given uncertain time of onset.
NEJMNEJMNew England Journal of MedicineRandomized Controlled TrialApixaban versus Warfarin in Patients with Atrial Fibrillation (ARISTOTLE)IIa·B-RClass IIaLOE B-RACC/AHAA rate-control strategy is reasonable when the duration of AF is uncertain and the patient is hemodynamically stable. 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline
- Telemetry; recheck magnesium and TSH; repeat troponin to rule out ischemia.
- Continue home lisinopril and HCTZ; hold if hypotensive with rate control.
JACCACCJ Am Coll CardiolPractice Guideline2017 ACC/AHA Guideline for the Management of High Blood Pressure in AdultsI·AClass ILOE AACC/AHAIn adults with hypertension, blood-pressure-lowering medication is recommended to reduce cardiovascular events. 2017 ACC/AHA Hypertension Guideline
- Hold metformin inpatient; scheduled insulin with point-of-care glucose monitoring.
Diabetes CareADADiabetes CareStandards of CareDiabetes Care in the Hospital: Standards of Care in DiabetesAGrade AHighADAFor most non-critically ill hospitalized patients, scheduled insulin is preferred over sliding-scale-only or oral agents. ADA Standards of Care in Diabetes
- Renally dose medications; avoid nephrotoxins; apixaban appropriate at current eGFR.
Kidney IntKIKidney InternationalPractice GuidelineKDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD1A1AHighKDIGOAdjust medication dosing to kidney function and avoid nephrotoxic agents in patients with chronic kidney disease. KDIGO 2024 CKD Guideline
- Continue home CPAP overnight; monitor overnight oximetry.
AASMAASMJ Clin Sleep MedPractice GuidelineTreatment of Adult Obstructive Sleep Apnea with Positive Airway PressureStrongStrongGRADEAASMPositive airway pressure therapy is recommended for the treatment of adults with obstructive sleep apnea. AASM OSA Practice Guideline
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Admitted from the ED in atrial fibrillation with rapid ventricular response, HR 138. Rate control started; troponin flat, TSH pending.
Rate-controlled overnight at HR 86. Anticoagulation started after CHA₂DS₂-VASc review. Echo ordered to assess structure.
Tolerating oral rate control. Echo shows preserved EF, no thrombus. Planning transition to outpatient follow-up.
Given a CHA₂DS₂-VASc of 4 and preserved renal function, apixaban 5 mg twice daily is preferred over warfarin.
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Elevated thromboembolic risk; anticoagulation is recommended unless contraindicated.
Points: HTN 1, age 65–74 1, diabetes 1, female 1.
Base it on CHA₂DS₂-VASc, not the rhythm pattern. For this patient the score is 4, a stroke risk high enough that a direct oral anticoagulant is preferred over warfarin.CirculationAHACirculationPractice Guideline2023 ACC/AHA/ACCP/HRS Guideline for the Management of Atrial FibrillationI·AClass ILOE AACC/AHAIn patients with AF and elevated stroke risk, oral anticoagulation is recommended; a DOAC is preferred over warfarin in eligible patients. 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline
- A DOAC is preferred over warfarin for nonvalvular AF.
- Paroxysmal AF carries a stroke risk similar to persistent AF.
Anticoagulate at CHA₂DS₂-VASc ≥2 (men) or ≥3 (women); prefer a DOAC over warfarin for nonvalvular AF.
H&P
History of Present Illness
72-year-old with hypertension, type 2 diabetes, and hyperlipidemia, admitted from the ED with new-onset atrial fibrillation and rapid ventricular response to 138. Two days of intermittent palpitations and brief exertional dyspnea, worse overnight. Denies chest pain, pressure, syncope, presyncope, fever, or recent illness. No prior arrhythmia; last echocardiogram normal.
Past Medical History
- Hypertension
- Type 2 diabetes mellitus (A1c 7.4%)
- Hyperlipidemia
- Chronic kidney disease, stage 2
- Obstructive sleep apnea, on CPAP
- Osteoarthritis
Home Medications
- Lisinopril 20 mg daily
- Metformin 1000 mg twice daily
- Atorvastatin 40 mg nightly
- Hydrochlorothiazide 25 mg daily
- Aspirin 81 mg daily
Allergies
Penicillin (rash).
Social History
Former smoker, 15 pack-years, quit 10 years ago. Occasional alcohol. Lives with spouse; independent in all activities of daily living.
Family History
Father with coronary artery disease; mother with ischemic stroke.
Review of Systems
Constitutional: No fever, chills, or unintentional weight loss.
Cardiovascular: Positive for palpitations; no chest pain, orthopnea, or PND.
Respiratory: Mild exertional dyspnea; no cough, wheeze, or hemoptysis.
Gastrointestinal: No nausea, vomiting, abdominal pain, or melena.
Genitourinary: No dysuria, frequency, or hematuria.
Neurologic: No focal weakness, numbness, headache, or visual change.
Endocrine: No heat or cold intolerance, polyuria, or polydipsia.
Physical Examination
Vitals: BP 138/86, HR 86 (rate-controlled), RR 16, SpO₂ 97% on room air, T 36.8 °C.
General: Well-appearing, comfortable, in no acute distress.
HEENT: Normocephalic, atraumatic; moist mucous membranes; no JVD.
Cardiovascular: Irregularly irregular rhythm; normal S1/S2; no murmurs, rubs, or gallops.
Pulmonary: Clear to auscultation bilaterally; no wheezes, rales, or rhonchi.
Abdomen: Soft, non-tender, non-distended; normoactive bowel sounds.
Extremities: Warm and well-perfused; no peripheral edema or calf tenderness.
Neurologic: Alert and oriented ×3; no focal motor or sensory deficits.
Studies & Data
ECG: Atrial fibrillation with RVR; no acute ST-segment changes.
Labs: Na 139, K 4.2, Cr 1.1 (baseline), Mg 1.9; troponin negative ×2; TSH pending.
Imaging: Chest radiograph without acute cardiopulmonary process.
Assessment & Plan
72-year-old with new-onset atrial fibrillation and rapid ventricular response, now rate-controlled and hemodynamically stable, on a background of hypertension and type 2 diabetes.
- Start apixaban 5 mg PO twice daily for stroke prevention (CHA₂DS₂-VASc 4).
- Rate control with metoprolol tartrate 25 mg PO twice daily; titrate to HR <110.
- Defer cardioversion; rate-control strategy given uncertain time of onset.
- Telemetry; recheck magnesium and TSH; repeat troponin to rule out ischemia.
- Continue home lisinopril and HCTZ; hold if hypotensive with rate control.
- Hold metformin inpatient; scheduled insulin with point-of-care glucose monitoring.
- Renally dose medications; avoid nephrotoxins; apixaban appropriate at current eGFR.
- Continue home CPAP overnight; monitor overnight oximetry.
Admitted from the ED in atrial fibrillation with rapid ventricular response, HR 138. Rate control started; troponin flat, TSH pending.
Rate-controlled overnight at HR 86. Anticoagulation started after CHA₂DS₂-VASc review. Echo ordered to assess structure.
Tolerating oral rate control. Echo shows preserved EF, no thrombus. Planning transition to outpatient follow-up.
Given a CHA₂DS₂-VASc of 4 and preserved renal function, apixaban 5 mg twice daily is preferred over warfarin.
Elevated thromboembolic risk; anticoagulation is recommended unless contraindicated.
Points: HTN 1, age 65–74 1, diabetes 1, female 1.
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