GP CCE Cases · cardiovascular-health
Newly detected atrial fibrillation — CCE clinical encounter
CCE-style clinical encounter: a 67-year-old man whose irregular pulse is confirmed as atrial fibrillation on ECG. The candidate must work up new AF, calculate CHA2DS2-VASc aloud, start a DOAC at the correct dose, set a lenient rate target, and safety-net the unstable features.
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Prompt
A 67-year-old retired plumber attends for a blood pressure check. His pulse is irregularly irregular; 12-lead ECG confirms atrial fibrillation at 104 beats per minute. He has treated hypertension, type 2 diabetes, and drinks six mid-strength beers nightly. He feels 'a bit fluttery' when climbing stairs but is otherwise well. Weight 84 kg; no prior stroke; echo arranged.
Objectives
- Confirm and explain the diagnosis from the ECG, and complete the new-AF workup (TSH, renal function, echo, trigger screen). [5]
- Calculate CHA2DS2-VASc aloud with the patient and state the anticoagulation threshold it crosses. [1]
- Initiate apixaban 5 mg twice daily, explaining why DOACs beat warfarin and aspirin with trial numbers. [2]
- Start rate control toward the lenient RACE II target. [3]
- Address alcohol as a causal driver and give explicit instability safety-netting. [4][5]
References5ShowHide
- [1]Lip GY et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest, 2010.PMID 19762550
- [2]Granger CB et al. Apixaban versus warfarin in patients with atrial fibrillation. The New England journal of medicine, 2011.PMID 21870978
- [3]Van Gelder IC et al. Lenient versus strict rate control in patients with atrial fibrillation. The New England journal of medicine, 2010.PMID 20231232
- [4]Gallagher C et al. Alcohol and incident atrial fibrillation - A systematic review and meta-analysis. International journal of cardiology, 2017.PMID 28867013
- [5]Joglar JA et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2024.PMID 38033089