Atrial Fibrillation — Written Clinical Reasoning

SAQ 1 — Integrated AF Management (20 marks, 30 minutes)

Prompt: Outline your integrated management plan for this patient, addressing stroke prevention, symptom/rhythm strategy, comorbidity optimisation, and medication changes. Justify each decision with reference to evidence and guidelines. ^[1]

Model Answer

Problem list (4 marks):

1. Persistent atrial fibrillation, symptomatic (palpitations, exertional dyspnoea) — newly diagnosed
2. High stroke risk — CHA₂DS₂-VASc requires calculation
3. Ischaemic heart disease (prior NSTEMI) — antiarrhythmic choice constrained
4. Type 2 diabetes (HbA1c 62) — suboptimal control
5. Hypertension — BP above target at 146/88
6. Stage 3A CKD (eGFR 52) — affects DOAC dosing and drug choices
7. Obesity (BMI 33) — modifiable AF risk factor
8. Dual antiplatelet/antithrombotic issue — currently on aspirin alone; needs anticoagulation ^[1]

Stroke prevention — anticoagulation (5 marks): ^[1]

CHA₂DS₂-VASc score: age 65–74 (1), hypertension (1), diabetes (1), vascular disease/prior MI (1) = 4 (male, so no sex point). A score of 2 or more in men warrants anticoagulation. He should be started on a DOAC. ^[1]

Apixaban is the preferred DOAC based on ARISTOTLE (PMID 21870978), which showed apixaban was superior to warfarin — 21% reduction in stroke/systemic embolism, 31% reduction in major bleeding, and 11% reduction in all-cause mortality. ^[1]

Dose check for apixaban: dose reduction to 2.5mg BID requires two of three criteria (age 80+, weight 60 kg or under, creatinine 133+ micromol/L). He meets none of these (age 72, weight 78 kg, creatinine 125), so apixaban 5mg BID is the correct dose. ^[1]