Atrial fibrillation: A patient’s journey

Follow the story of John, who has been newly diagnosed with atrial fibrillation (AF) and subsequently develops co-morbidities. Find out about the associated risk factors during the course of his disease and the impact on his and his family’s life.

65
Atrial fibrillation symptoms emerge
66
Atrial fibrillation diagnosis
Anticoagulation prescription
69
Living with atrial fibrillation
71
The added complication of diabetes
Renal function decline
End
What could have been done differently to reduce John’s risk of renal decline while protecting him from stroke and its potential catastrophic consequences?

Age 65 65

Atrial fibrillation symptoms emerge

John is 65 years old and works as a financial analyst for an engineering company. He is married and has two children who have just started families of their own. He works long hours and has been experiencing fatigue and increasing bouts of dizziness in the last couple of months.1

Did you know?

Many patients with AF have both symptomatic and asymptomatic episodes of AF.2

Age 66 66

Atrial fibrillation diagnosis

John visits his family doctor for a routine check-up, who makes a diagnosis of AF based on his symptoms and tests. His doctor explains that AF increases his risk of stroke and needs to be managed carefully.3 The doctor also tests John’s kidney function and finds that his creatinine clearance is 85 ml/min, indicating normal renal function. She is relieved about these results because she knows that renal impairment can further increase the risk of stroke.

Did you know?

Approximately 98% of patients with AF have at least one co-morbidity and approximately 63% have four or more co-morbidities.4

Age 66 66

Anticoagulation prescription

John’s doctor’s aim is to help protect him from stroke, so she assesses his need for anticoagulation. The ESC guidelines state that oral anticoagulants are indicated in men with a CHA2DS2-VASc score of ≥2. John’s doctor notes his resting blood pressure is 145/93, giving him a CHA2DS2-VASc score of +2 (for his blood pressure and age).2 To help protect him from his elevated risk of stroke, she prescribes John with warfarin.

Did you know?

AF is associated with a 4- to 5-fold increase in the risk of stroke.5

Age 69 69

Living with atrial fibrillation

At the age of 69 years, John decides to retire – he tries to continue with his life by visiting his grandchildren whenever he can and relaxing with his wife; however, he is less active than he used to be, and he is drinking and eating more than he did while he was working. His weight has increased by 10 kg in the last 6 months. He thinks maybe he should try to lose weight by exercising more frequently and reducing his alcohol consumption.

Did you know?

Up to 40% of patients with AF have diabetes.6-9

Age 71 71

The added complication of diabetes

John has noticed that he is increasingly thirsty and needs to urinate more frequently. These symptoms and his weight gain are starting to worry him. Urine and blood tests performed by his doctor indicate that John has developed type 2 diabetes. His CHA2DS2-VASc score is now +3 (for his blood pressure, age and diabetes).10 John’s doctor is now very concerned and explains to John that, as a patient with AF who also has diabetes, he now has an especially high risk of stroke.5 She gives John his prescription and reminds him of the importance of taking his medication as prescribed.

Did you know?

Risk of death after a stroke is greater if a patient has diabetes.11

Age 71 71

Renal function decline

The doctor also tests John’s kidney function again and finds that his creatinine clearance has now decreased to 48 ml/min. After several confirmatory tests, she concludes that John’s kidney function has worsened dramatically.

Did you know?

Diabetes doubles the rate of kidney function decline12

End End

What could have been done differently to reduce John’s risk of renal decline while protecting him from stroke and its potential catastrophic consequences?

Protecting patients with AF from stroke means seeing the bigger picture, taking into account the efficacy of the anticoagulation agent, as well as avoiding bleeding events and thinking about the effect of treatment on a patient’s renal function.
The 2019 AHA/ACC/HRS guidelines state that in patients with AF (like John), NOACs may be associated with lower risks of adverse renal outcomes than vitamin K antagonists.13 For more information, see this newsletter.

Did you know?

In patients with AF, the risks of stroke, bleeding and death are further increased in those with renal impairment compared with those without.14,15

Show references

Approval code: PP-M_RIV-ALL-0055-1

  1. NHS. Atrial Fibrillation. 2020. Available at: https://www.nhs.uk/conditions/atrial-fibrillation/ [accessed 19 February 2020].
  2. Kirchhof P, Benussi S, Kotecha D et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016;18:1609–1678.
  3. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991;22:983–988
  4. LaMori JC, Mody SH, Gross HJ et al. Burden of comorbidities among patients with atrial fibrillation. Ther Adv Cardiovasc Dis 2013;7:53–62.
  5. Ashburner JM, Go AS, Chang Y et al. Effect of diabetes and glycemic control on ischemic stroke risk in AF patients: ATRIA study. J Am Coll Cardiol 2016;67:239–247.
  6. Patel MR, Mahaffey KW, Garg J et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365:883–891.
  7. Giugliano RP, Ruff CT, Braunwald E et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013;369:2093–2104.
  8. Granger CB, Alexander JH, McMurray JJ et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365:981–992.
  9. Steinberg BA, Gao H, Shrader P et al. International trends in clinical characteristics and oral anticoagulation treatment for patients with atrial fibrillation: results from the GARFIELD-AF, ORBIT-AF I, and ORBIT-AF II registries. Am Heart J 2017;194:132–140.
  1. Kirchhof P, Benussi S, Kotecha D et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016;37:2893–2962.
  2. Bansilal S, Bloomgarden Z, Halperin JL et al. Efficacy and safety of rivaroxaban in patients with diabetes and nonvalvular atrial fibrillation: The Rivaroxaban Once-daily, Oral, Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF Trial). Am Heart J 2015;170:675–682.
  3. Hemmelgarn BR, Zhang J, Manns BJ et al. Progression of kidney dysfunction in the community-dwelling elderly. Kidney Int 2006;69:2155–2161.
  4. January CT, Wann LS, Calkins H et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in collaboration with the Society of Thoracic Surgeons. Circulation 2019;140:e125–e151.
  5. Boriani G, Laroche C, Diemberger I et al. Glomerular filtration rate in patients with atrial fibrillation and 1-year outcomes. Sci Rep 2016;6:30271.
  6. Fanikos J, Burnett AE, Mahan CE, Dobesh PP. Renal function considerations for stroke prevention in atrial fibrillation. Am J Med 2017;130:1015–1023.