Cardiovascular Critical Care I

For patients with AF/flutter taking anticoagulants who undergo cardiac stenting, the strongly

recommended approach is to manage with dual therapy (anticoagulant + P2Y12 inhibitor).

Clopidogrel was the most widely studied P2Y12 inhibitor in combination with anticoagulation (J Am

Coll Cardiol. 2021;77(5):629-658; N Engl J Med. 2019;380(16):1509-1524). Direct oral anticoagulant

medications have shown superior safety profiles to vitamin K antagonists in combination with

P2Y12 inhibitors. Guidance documents state that if triple antithrombotic therapy is to be used,

it should be used for the shortest period possible for patients with a perceived high thrombotic

risk. The guidance documents do not provide objective criteria for triple therapy use because they

strongly favor dual therapy with an oral anticoagulant and P2Y12 inhibitor. Dual therapy reduces

the risk of bleeding compared with triple therapy without sacrificing ischemic efficacy. Further

details surrounding recommendations are beyond the scope of this chapter but can be found in the

2023 ACC/AHA/ACCP/HRS Guideine for the Diagnosis and Management of Atrial Fibrillation

Guidelines

Patient Case (Continued)

The appropriate intervention has been made from question 5, and the patient has not required any need for pac-

ing. For the next 48 hours, J.M. continues on inotrope therapy and is being diuresed (his net fluid balance has

been 1250 and 900 mL negative each day for the past 2 days). The transthoracic ECHO results showed J.M.’s

ejection fraction to be 15%–20%, with a dilated, hypokinetic LV, severe mitral regurgitation, and dilated atria.

No evidence of intracardiac thrombus was seen, but this could not be ruled out.

J.M. has had increasing premature atrial complexes on telemetry, and his heart rate has consistently been

83–96 beats/minute. He is receiving dobutamine at 5 mcg/kg/minute and a furosemide infusion at 10 mg/

hour. The team is notified that J.M. has gone into AF with rapid ventricular response and a heart rate of 132

beats/minute (he has been in AF for about 30 minutes). His blood pressure is now 83/52 mm Hg. Which

treatment plan would be most preferred for this patient?

J.M.’s BP and HR improved after the previous intervention; however, he remains in AF. The team is now

concerned about evaluating the patient for anticoagulation. You are asked to provide input about the appro-

priateness of anticoagulation, given the patient’s clinical course and past medical history. His calculated

CHA2DS2-VASc score is 5 and HAS-BLED score is 5. The physician is considering anticoagulation with a

heparin infusion while the patient is in the ICU and asks for a recommendation. Which is the most appro-

priate response?

be reasonable to either initiate or withhold anticoagulation.

be reasonable to initiate heparin anticoagulation.

coagulation is still likely warranted eventually, given the patient’s CHA2DS2-VASc score.

agulation is not warranted.