T.T. is a 68 -year-old woman who presents to the cardiology clinic for a routine follow-up. Her
medical history is significant for HTN, dyslipidemia, a transient ischemic attack (TIA) 2 weeks
ago, paroxysmal AF, and HFrEF with an ejection fraction (EF) of 30%. Implantable cardioverter defibrillator
interrogations over the past year reveal that she has remained in sinus rhythm. Her
current cardiac medications include aspirin 81 mg daily, metoprolol succinate 100 mg daily,
atorvastatin 40 mg daily, losartan 50 mg daily, digoxin 125 mcg daily, amiodarone 200 mg daily,
and apixaban 5 mg twice daily. Her vital signs in the clinic are blood pressure 105/70 mm Hg and
heart rate 62 beats/minute. Today, as you review her medications, the patient says that
she wishes she did not have to take so many medications. Which one of the following is best
to recommend for discontinuation in this patient?
A. Anticoagulation is not needed before cardioversion, but it should be followed by 4 weeks of anticoagulation with dose-adjusted warfarin.
Hemodynamically stable, no need to cardiovert today, but does need anticoagulation
B. Start treatment-dose heparin immediately, but delay cardioversion by 48 hours, followed by 4 weeks of
anticoagulation with dose-adjusted warfarin after cardioversion.
Does not need cardioversion in the next few days due to hemodynamic stability, also no need to do
heparin drip for 48 hours
C. Start treatment-dose heparin immediately and proceed with cardioversion now, followed by 4 weeks of anticoagulation with dose-adjusted warfarin after cardioversion.
Hemodynamically stable, no need cardioversion today, but does need anticoagulation
D. Delay cardioversion and begin anticoagulation with dose-adjusted warfarin for 3 weeks before and 4
weeks after cardioversion.
Correct: Hemodynamically stable, needs anticoagulation prior to cardioversion at least 3 weeks and then after DCC