Prescriptive Case Study: Ms. Tesla Comes Into The Cardiology Office

Prescriptive Case Study Three Ms. Tesla comes into the cardiology office, complaining of fatigue, palpitations, shortness of breath with mild activity, ongoing consistently for the past week without any chest pain or syncopal episodes. She is a 75-year-old woman with a history of atrial fibrillation (AFib), controlled type 2 diabetes, myocardial infarction (MI) with a history of percutaneous coronary intervention to right coronary artery, stage IV chronic renal failure, and a mild mitral regurgitation on ECHO 7 years ago. Her in clinic ECG show AFib with ventricular rate of 111 and mild left ventricular hypertrophy, pulse 99 and irregular, blood pressure of 102/72, and grade 1/6 systolic murmur with no rubs or gallops. The rest of the physical
Tesla is hemodynamically stable, without evidence of left atrial thrombus or heart failure. Her CHA2DS2-VASc score is at 6, which requires medication for stroke prevention with an anticoagulant (Epocrates, 2018). Ms. Tesla will be given a prescription for apixaban, an oral anticoagulant used for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (Burchum & Rosenthal, 2016). Its metabolism occurs in the liver and eliminated in urine and feces. Due to the route of elimination, apixaban levels may accumulate in patients with renal impairment, but renal dosing for the drug is available (Burchum & Rosenthal, 2016). As with any anticoagulant, the most common adverse effect is bleeding, but compared with warfarin, the risk of major bleeding and hemorrhagic stroke is much lower (Burchum & Rosenthal, 2016). Patients with serum creatinine level greater than or equal to 1.5 mg/dL, the delayed excretion of apixaban can increase bleeding risk. Patients with renal impairment receive a prescription for apixaban tablets dosed at 2.5 mg twice daily (Burchum & Rosenthal, 2016). The current recommendation requires long term use of an anticoagulant for those taking an antidysrhythmic drug for control ventricular rate along with an antiplatelet drug, such as the aspirin that Ms. Tesla is currently taking (Burchum & Rosenthal, 2016). If her cardiac rhythm does not go back to normal sinus rhythm and or she continues to have symptomatic AFib, she will require electrical or pharmacological cardioversion at a hospital setting following 3 to 4 weeks of oral anticoagulation therapy (Epocrates,