Atrial Fibrillation in Heart Failure Managed with Warfarin and Digoxin and Complicated by Hemorrhagic and Thrombotic Events: A Case Report from a Rural Kenyan Hospital
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Atrial fibrillation (AF) is the most common supraventricular tachyarrhythmia and is characterized clinically by irregular palpitations, dizziness, presyncope and syncope, effort intolerance, an apical-radial pulse deficit, and heart failure. The diagnosis is confirmed by an electrocardiogram showing an irregularly irregular ventricular rhythm, absent P waves, and the presence of fibrillatory waves. In Sub-Saharan Africa, the prevalence of AF is about 4.3% and 0.7% in individuals aged ≥40 years and aged ≥70 years, respectively, while the main risk factors for AF are hypertension, cardiomyopathy, and rheumatic heart disease. Rate control using beta blockers, the use of antiarrhythmics, anticoagulation using warfarin or direct oral anticoagulants to prevent stroke, cardiovascular risk factor reduction, and radiofrequency catheter ablation in select patients are the main objectives in the management of AF as per the current guidelines by the European Society of Cardiology (ESC), the American Heart Association (AHA), the American College of Cardiology (ACC), etc. This case report highlights the challenges of managing AF in congestive heart failure (CHF) in a rural Kenyan hospital in which the patient had hemorrhagic complications from warfarin toxicity followed by stroke after warfarin withdrawal and the therapeutic effects of adding digoxin to achieve better rate control and improve the CHF morbidity.
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Hindricks, G., et al., 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J, 2021. 42(5): p. 373-498.
Staerk, L., et al., Atrial Fibrillation: Epidemiology, Pathophysiology, and Clinical Outcomes. Circ Res, 2017. 120(9): p. 1501-1517.
Noubiap, J.J. and U.F. Nyaga, A review of the epidemiology of atrial fibrillation in sub-Saharan Africa. J Cardiovasc Electrophysiol, 2019. 30(12): p. 3006-3016.
Jardine, R.M., J. Fine, and I.W. Obel, A survey on the treatment of atrial fibrillation in South Africa. S Afr Med J, 2014. 104(9): p. 623-7.
Semakula, J.R., et al., Anticoagulation in sub-Saharan Africa: Are direct oral anticoagulants the answer? A review of lessons learnt from warfarin. Br J Clin Pharmacol, 2021. 87(10): p. 3699-3705.
Hart, R.G., et al., Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med, 1999. 131(7): p. 492-501.
Carnicelli, A.P., et al., Direct Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation: Patient-Level Network Meta-Analyses of Randomized Clinical Trials With Interaction Testing by Age and Sex. Circulation, 2022. 145(4): p. 242-255.
Connolly, S.J., et al., Rivaroxaban in Rheumatic Heart Disease-Associated Atrial Fibrillation. N Engl J Med, 2022. 387(11): p. 978-988.
White, H.D., et al., Comparison of outcomes among patients randomized to warfarin therapy according to anticoagulant control: results from SPORTIF III and V. Arch Intern Med, 2007. 167(3): p. 239-45.
Van Gelder, I.C., et al., Rate control in atrial fibrillation. Lancet, 2016. 388(10046): p. 818-28.
Lopes, R.D., et al., Digoxin and Mortality in Patients With Atrial Fibrillation. J Am Coll Cardiol, 2018. 71(10): p. 1063-1074.
Dorian, P. and P. Angaran, Beta-Blockers and Digoxin in Atrial Fibrillation: Back to the Future. Can J Cardiol, 2023. 39(11): p. 1594-1597.
Ferrari, F., I. Santander, and R. Stein, Digoxin in Atrial Fibrillation: An Old Topic Revisited. Curr Cardiol Rev, 2020. 16(2): p. 141-146.
null, n., et al., 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Journal of the American College of Cardiology, 2024. 83(1): p. 109-279.
Mason, P.K., et al., Impact of the CHA2DS2-VASc score on anticoagulation recommendations for atrial fibrillation. Am J Med, 2012. 125(6): p. 603.e1-6.
Pisters, R., et al., A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest, 2010. 138(5): p. 1093-100.
Heidenreich, P.A., et al., 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2022. 145(18): p. e895-e1032.
Sonuga, B.O., et al., Profile and anticoagulation outcomes of patients on warfarin therapy in an urban hospital in Cape Town, South Africa. Afr J Prim Health Care Fam Med, 2016. 8(1): p. e1-8.
Echt, D.S. and J.N. Ruskin, Use of Flecainide for the Treatment of Atrial Fibrillation. Am J Cardiol, 2020. 125(7): p. 1123-1133.
Sestito, A. and E. Molina, Atrial fibrillation and the pharmacological treatment: the role of propafenone. Eur Rev Med Pharmacol Sci, 2012. 16(2): p. 242-53.
Istratoaie, S., et al., Efficacy of amiodarone for the prevention of atrial fibrillation recurrence after cardioversion. Cardiovasc J Afr, 2021. 32(6): p. 327-338.
Tsantes, A.G., et al., Sepsis-Induced Coagulopathy: An Update on Pathophysiology, Biomarkers, and Current Guidelines. Life, 2023. 13(2): p. 350.
Induruwa, I., et al., Sepsis-driven atrial fibrillation and ischaemic stroke. Is there enough evidence to recommend anticoagulation? Eur J Intern Med, 2022. 98: p. 32-36.
Gallus, A.S., et al., Consensus guidelines for warfarin therapy. Recommendations from the Australasian Society of Thrombosis and Haemostasis. Med J Aust, 2000. 172(12): p. 600-5.
Ambrosy, A.P., P.S. Pang, and M. Gheorghiade, Digoxin for Worsening Chronic Heart Failure. JACC: Heart Failure, 2016. 4(5): p. 365-367.
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