Proper management of anticoagulation in a case of frail elderly patient with permanent atrial fibrillation and renal lithiasis – the importance of a multidisciplinary team

Objective: Our aim was to emphasize the importance of multidisciplinary team for a proper treatment mana-gement of eldery patients with atrial fibrillation (AF). The risks of thromboembolic and hemorrhagic events in patients with AF both increase with age.

Methods: 83-years-old woman with a history of perma-nent AF with ineffective anticoagulant control, conges-tive heart failure (CHF), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), chro-nic venous insufficiency, was admitted with dyspnea, orthopnea and osteoarticular pain. Clinical examinati-on: BMI=24kg/m2, BP=130/80 mmHg, HR=104bpm, arrhythmic, self-reported exhaustion, dyspnea-ortho-pnea, lung auscultation: no rales or crackles, ochre der-matitis, left shoulder pain, polyuria, bilateral negative costovertebral angle tenderness (CVAT).

Results: ECG: AF, 80 bpm, QRS axis 0 degrees, ne-gative T waves V4-V6 (lateral territory), DII, D III, aVF (inferior). Chest radiography: cardiomegaly and aortic dilatation. Laboratory: INR=1.17; Hgb=12.8g/ dl; eGFR =57ml/min/1.73m2; urinalysis=500 leu/ uL, Bld=300Ery/uL, P=30mg/dl; positive urine cul-ture: Escherichia Coli >100.000 UFC/ml. CHA2DS2-VASc=5p; HAS-BLED=3p. Groningen Frailty Indicator (GFI) was 5(GFI: frailty ≥4). A shifting from VKA to NOACs – Dabigatran 110mg b.i.d. was initiated. After a week of effective anticoagulant and antibiotic treatment patient presents: persistent macroscopic hematuria, Hgb 10.8g/dl (2 units decrease), pain in the back that radiates to the lower anterior abdomen, right positive CVAT. Abdominal ultrasound: bilateral renal lithiasis, right lower calyx stone sized 2 cm, right kidney hydro-nephrosis grade 2, normal urinary bladder. Abdominal radiography: no radio-opaque stones; lumbar scoliosis. The patient was evaluated in a multidisciplinary team: cardiologist, urologist, radiologist and geriatrician in order to estimate the risk-benefit ratio of anticoagulan-tion. NOAC treatment was maintained with indication of apixaban 2.5mg b.i.d., urology and cardiology follow up if needed (hematuria).

Conclusions: Interdisciplinary colaboration lead to im-proved treatment recommendations based on updated and evidence-based knowledge. The improved safety profile of NOACs may enable treatment of elderly pa-tients with AF. A personalised approach is recommen-ded for the NOAC type to use in older patients.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)