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Advanced Practice Nursing in Acute and Critical Care Environments: National ACNP Study

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Title: Advanced Practice Nursing in Acute and Critical Care Environments: National ACNP Study


1
CLINICAL CASES

2
Atrial Fibrillation Case Study 2
  • An 81-year-old white female with a history of
    chronic, non-valvular AF, a history of a previous
    ischemic stroke, and a history of mild congestive
    heart failure has been on a combination of
    clopidogrel and aspirin therapy because she was
    found to be intolerant of warfarin.
  • She is on a proton pump blocker, an ACE
    inhibitor, a diuretic, and digoxin.
  • She is admitted to the hospital for a GI bleed,
    and is found to have a hematocrit of 29 and a
    hemoglobin of 9.8. The aspirin and clopidogrel
    are discontinued.

3
Atrial Fibrillation Case Study 2
  • The patient stabilizes, and the cardiologist is
    consulted to determine the subsequent course of
    her antithrombotic treatment. She has a HAS-BLED
    score of 3.
  • It is your opinion that
  •  
  • Because of the documented GI bleed, the patient
    should not be treated with antithrombotic agents,
    because the risk of bleeding outweighs the risk
    of stroke and its complications.
  • Because of the patient's risk profile, there
    should be an attempt to provide
    thromboprophylaxis against embolic stroke.

4
Atrial Fibrillation Case Study 2
  • The cardiologist has determined that this patient
    requires antithrombotic management for stroke
    prevention.
  • At this point you would most likely
  •  
  • Try the patient on warfarin again
  • Try to re-introduce clopidogrel and aspirin
  • Treat the patient with aspirin alone
  • Introduce a non-monitored oral anticoagulant to
    the patient's regimen.  

5
Atrial Fibrillation Case Study 3
  • An 82-year-old man with hypertension and diabetes
    has permanent atrial fibrillation.
  • He has a history of spinal stenosis and walks
    with a walker and has a history of falls.
  • He has a CHADS-VASc score of 3, and a HASBLED
    score of 2.
  • Which regimen would you prescribe for prophylaxis
    against thromboembolism?

6
Atrial Fibrillation Case Study 3
  • Which regimen would you prescribe for prophylaxis
    against thromboembolism?
  1. Warfarin (INR 2.0-3.0)
  2. Warfarin (INR 1.5-2.0)
  3. Aspirin 81 mg daily
  4. Aspirin 81 mg clopidogrel 75 mg daily
  5. An oral Factor Xa or direct thrombin inhibitor

7
Atrial Fibrillation Case StudyAnticoagulation in
Patients at Risk of Falls
persons taking warfarin must fall about 295
(535/1.81) times in 1 year for warfarin not to be
the optimal therapy
8
Atrial Fibrillation Case Study 4
  • A 71-year-old man with AF, heart failure, and a
    prior history of stroke presents with unstable
    angina and proceeds to cardiac catheterization
    where a culprit lesion is identified. Optimal
    management includes
  • Placement of a drug-eluting stent with plan to
    continue anticoagulation in addition to 1 year of
    dual antiplatelet therapy
  • Placement of a drug-eluting stent with 1 year of
    dual antiplatelet therapy alone
  • Placement of a bare metal stent with plan to
    continue anticoagulation in addition to 1 month
    of dual antiplatelet therapy
  • Placement of a bare metal stent with 1 month of
    dual antiplatelet therapy alone

9
Atrial Fibrillation Case Study 5
  • A 67-year-old female with a history of mitral
    stenosis with subsequent mechanical mitral valve
    replacement has AF.
  • Which of the following anticoagulants can be used
    for stroke prevention in this patient?
  • Warfarin
  • Dabigatran
  • Apixaban
  • Rivaroxaban
  • All of the above

10
Atrial Fibrillation Knowledge Assessment
Question
  • The major potential benefits of the new
    non-monitored oral anticoagulants include
  • Rapid therapeutic anticoagulant effect
  • Greater safety with regards to intracranial
    hemorrhage
  • Proven reversal agent
  • All of the above
  • Both 1 and 2

11
Atrial Fibrillation Case Study 6
  • An 82-year-old man with AF has had several
    admissions over the past 6 months for heart
    failure complicated by worsening renal function.
    His creatinine clearance is currently 20 mL/min
    but frequently fluctuates to 10-15 mL/min. He has
    a HAS-BLED score of 3.
  • The best anticoagulant regimen for stroke
    prevention is
  • Dabigatran 150 mg twice daily
  • Dabigatran 75 mg twice daily
  • Warfarin titrated to goal INR 2-3
  • Rivaroxaban 20 mg once daily
  • Rivaroxaban 15 mg once daily

12
Atrial Fibrillation Case Study 7
  • A 79-year-old woman with a CHADS-VASc score of 2
    who has been on warfarin for the past 2 years
    returns to clinic for routine follow-up.
  • Her INR control has been excellent and she has
    never experienced a stroke or had significant
    bleeding. Her HAS-BLED score is 2.
  • Her complaints today are thinning hair, cold
    intolerance, and fatigue.
  • Her laboratory work is normal including a TSH.

13
Atrial Fibrillation Case Study 7
  • Which of her symptoms could be due to warfarin?
  • Thinning hair
  • Cold intolerance
  • Fatigue
  • Both 1 and 2
  • All of the above

14
Atrial Fibrillation Case Study 8
  • A 69-year-old woman with AF and CHADS2 score of 4
    has a creatinine clearance that is stable at 40
    mL/min.
  • Which of the following anticoagulation regimens
    are suitable for her?
  • Dabigatran 150 mg twice daily
  • Dabigatran 75 mg twice daily
  • Rivaroxaban 20 mg once daily
  • Rivaroxaban 15 mg once daily
  • Both 1 and 4

15
Atrial Fibrillation Case Study 8
  • What would her options be if her creatinine
    clearance was stable at 25 mL/min?
  • Dabigatran 75 mg twice daily
  • Rivaroxaban 15 mg once daily
  • Only warfarin can be used in patients with
    creatinine clearance lt 30 mL/min
  • Both 1 and 2

16
Atrial Fibrillation Case Study 9
  • A 74-year-old man with AF on dabigatran is
    involved in a motor vehicle accident and needs
    emergency surgery.
  • It is unclear if he is taking this medication but
    the surgeon is concerned about operating on him
    if he is fully anticoagulated.

17
Atrial Fibrillation Case Study 9
  • Which of the following lab tests, if normal,
    would reassure the team that the patient is
    not anticoagulated?
  • INR (international normalized ratio)
  • aPTT (activated partial thromboplastin time)
  • PT (prothrombin time)
  • Bleeding time

18
Atrial Fibrillation Case Study 10
  • A 60-year-old man with AF has been on warfarin
    but it has been very difficult to control his
    INR. You have decided to switch to dabigatran.
    Which of the following is true regarding
    transitioning a patient from warfarin to
    dagibatran?
  • Start dabigatran when his INR lt 3
  • Start dabigatran when his INR lt 2
  • Start dabigatran 24 hours after his last dose of
    warfarin

19
Atrial Fibrillation Case Study 10
  • What if you decided to switch the patient to
    rivaroxaban?
  • Start rivaroxaban when his INR lt 3
  • Start rivaroxaban when his INR lt 2
  • Start rivaroxaban 24 hours after his last dose of
    warfarin
  •  

20
Atrial Fibrillation Case Study 11
  • A 78-year-old female with AF, systolic heart
    failure, hypertension, diabetes, and a history of
    significant GI bleeding has been on warfarin for
    many years but has had a difficult time
    controlling her INR with frequent
    supertherapeutic values despite intensive
    monitoring and titration of her warfarin dose.
    Her HAS-BLED score is 3. The best treatment
    option for her is
  • No antithrombotic therapy
  • Discontinue warfarin and start aspirin
  • Discontinue warfarin and start dabigatran
  • Discontinue warfarin and start rivaroxaban
  • Discontinue warfarin and start apixaban

21
Atrial Fibrillation Case Study 12
  • A 76-year-old woman with heart failure,
    hypertension, diabetes, and declining renal
    function (creatinine clearance 35 mL/min) has an
    embolic stroke due to newly diagnosed AF. She
    refuses to take warfarin.
  • What is the best validated antithrombotic regimen
    in this particular patient?
  • Aspirin
  • Aspirin and clopidogrel
  • Dabigatran
  • Apixaban
  • Rivaroxaban

22
Atrial Fibrillation Case Study 13
  • A 68-year-old man with a mechanical mitral valve
    develops AF.
  • The best anticoagulant option for him is
  • Warfarin
  • Dabigatran
  • Apixaban
  • Rivaroxaban
  • Aspirin

23
Atrial Fibrillation Case Study 14
  • A 76-year-old man with heart failure and
    hypertension undergoes successful catheter
    ablation for symptomatic AF.
  • Which of the following is true regarding his
    anticoagulation management?
  • He no longer requires anticoagulation now that he
    is in sinus rhythm
  • Patient should be on both aspirin and an
    anticoagulant
  • Patient should be on an anticoagulant alone
  • Aspirin and clopidogrel together is as effective
    as anticoagulation in these patients

24
Atrial Fibrillation Case Study 14
  • The cardiologist has determined that this patient
    requires antithrombotic management for stroke
    prevention. At this point you would most likely
  •  
  • Try the patient on warfarin again
  • Treat the patient with aspirin alone
  • Introduce the non-monitored oral anticoagulant,
    apixaban, into the patient's regimen
  • Introduce dabigatran into the patients regimen
  • Introduce rivaroxaban into the patients regimen
  •  

25
Atrial Fibrillation Case Study 15
  • A 75-year-old male with a history of chronic,
    non-valvular AF, diabetic renal disease, previous
    history of ischemic stroke, history of mild HF,
    and controlled hypertension has been on warfarin
    therapy. The HAS-BLED score is 4.
  • For the past 6 months, despite repeated visits
    for monitoring and warfarin dose adjustment, his
    INR has varied between 1.5 and 4.3.
  • His estimated GFR is 30 mL/min.

26
Atrial Fibrillation Case Study 15
  • At this point you would
  •  
  • Continue to try to stabilize his INR on warfarin
  • Change to aspirin alone
  • Introduce the non-monitored oral anticoagulant
    rivaroxaban into the patient's regimen
  • Introduce the non-monitored oral anticoagulant
    apixaban into the patient's regimen
  • Introduce the non-monitored oral anticoagulant
    dabigatran into the patient's regimen

27
Atrial Fibrillation Case Study 17
  • An 82-year-old man with hypertension, diabetes,
    mild congestive heart failure, and previous
    ischemic stroke, is diagnosed with atrial
    fibrillation.
  • He has not been taking any anticoagulants.

28
Atrial Fibrillation Case Study 17
  • Which regimen would you initiate for prophylaxis
    against stroke?
  1. Warfarin (INR 2.0-3.0)
  2. Aspirin 81 mg clopidogrel 75 mg daily
  3. Rivaroxaban
  4. Apixaban
  5. Dabigatran

29
Atrial Fibrillation Case Study 18
  • An 82-year-old man with hypertension, diabetes,
    mild CHF, and a previous ischemic stroke has
    permanent atrial fibrillation.
  • He has been on warfarin for about 5 years and his
    INR has remained constant between 2.3 and 2.7.
  • He has a HAS-BLED score of 3.

30
Atrial Fibrillation Case Study 18
  • Which regimen would you continue or switch to for
    prophylaxis against stroke?
  1. Continue current therapy with warfarin
  2. Aspirin 81 mg clopidogrel 75 mg daily
  3. Rivaroxaban
  4. Apixaban
  5. Dabigatran

31
Atrial Fibrillation Case Study 19
  • A 75-year-old man with a CHADS2 of 3 has been
    taking dabigatran 150 mg for SPAF. His estimated
    GFR was 55 mL/min 6 months ago and is now 40
    mL/min.
  • I would now
  • Continue to monitor patient
  • Switch patient to 75 mg dabigatran twice per day
  • Switch patient to warfarin
  • Switch patient to rivaroxaban
  • Start ASA and clopidogrel
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