1
NU665D
NU665D/ NU 665D | Primary Care Adult
Woman II | Qs & As| Grade A| 100%
Correct |(2025/ 2026 Update) Regis
A. Fib Patient Evaluation - ANS ✓-PE: Heart sounds
-EKG- LA dilation?
-TFTs: should be done during initial discovery/change in
condition (e.g. difficult to control rate)
-Electrolytes with Magnesium
-BUN/Creatinine (helpful when trying to decide if AAD or OAC)
-Echocardiogram: valvular disease or reduced LVEF
-Ambulatory monitoring: Holter
Stroke Risk in A.Fib - ANS ✓Thromboembolism: primary
morbidity assoc. w/ A.Fib. Thrombus formation and dislodgement
from left atrial appendage (LAA)
-Based on clinical risk factors and NOT on freq/duration of A.Fib
-Non-valvular meaning A. Fib presumably not r/t mitral valve
heart disease, specifically mitral stenosis
-In general ~48hrs for clot formation; if duration known to be
<48hrs, can cardiovert w/o AC
-Second option: transesophageal echo to confirm absence of LAA
thrombus
-Risk of thrombus is increased in first 3-4 weeks after DCCV,
when gradual return of atrial mechanical function can result in
high risk for thrombus
CHADS 2 - ANS ✓CHF (1)
HTN (1)
NU665D
, 2
NU665D
Age >75 (1)
DM (1)
Prior Stroke (2)
CHADS 2 VASC 2 - ANS ✓CHF (1)
HTN (1)
Age >75 (2)
DM (1)
Prior Stroke (2)
Vascular disease (1)
Age 65-74 (1)
Female (1)
If score >2, oral anticoagulants (or if non valvular A. Fib for prior
stoke, TIA)
If pt has nonvalvular A. Fib and CHADS2VASc2 score of 0,
reasonable to omit anticoag therapy
New Anticoagulants - ANS ✓-3 currently approved
-Tested against coumadin
-No sign. diff b/w the three of them except for S/Es
-Avoid potent Pgp inducers (rifampin, carbemazepine, phehytoin,
phenobarb, St. John's wort) as will decrease effect
-Riva and Apixa: Avoid potent inhibitors of CYP3A4 and Pgp
(Azoles, Protease inhibitors, mycins), as will INCREASE AC effect
Eliquis (apixaban) - ANS ✓Dose: 5mg BID
Renal adjustment: 2.5mg twice daily, must have 2 or more of the
following: Age >80yo, Body wt </= 60kg, Serum creatinine >/=
1.5mg/dL
Half life: 12 hours
Time to Peak: 3-4hours
Direct factor Xa inhibitor
NU665D
, 3
NU665D
Xarelto (rivaroxaban) - ANS ✓Dose: 20mg daily w/evening meal
of at least 500 calories for absorption
Renal Adjustment: CrCl 15-50mg once daily w/evening meal; CrCl
<15mL/min: avoid use
Half life: 5-13 hours
Peak: 2-4 hours
Director Factor Xa inhibitor
Pradaxa (dabigatran) - ANS ✓Dose: 150mg BID
Renal adjustment: 75mg BID; not adequately studied
>10% pts have GI distress
Half life: 12-17hours, Up to 28hours w/renal impairment
Peak: 1-2hours
Direct thrombin inhibitor
Coumadin - ANS ✓-Obtain baseline PT/INR and investigate if
abnormal
-Determine use of potential warfarin interactions (meds)
-Document target INR and RX warfarin tablet strength
-Provide pt edu on safety, monitoring, food and drug interactions
-Recommend 1st INR check on day 3-4
Coumadin Initiation - ANS ✓Day 1-3, initial dose: 5mg (10mg)
Day 3-4:
-1.0-1.3 Dose 7.5mg
-1.4-1.5 Dose 5mg
-1.6-1.8 Dose 5/2.5mg alternating dose
->1.0 Dose 2.5mg
->2.0 hold x1 day, then 2.5mg
Reversal agents: Vitamin K 1-10mg IV/PO (not SQ/IM); Takes 6
(IV) to 25 (PO) hours to reverse warfarin
INR interpretation - ANS ✓-No anticoagulation therapy level:
should be ~1.0
NU665D
, 4
NU665D
-Higher the number, greater risk of bleeding
-Anticoagulation therapy target level: 2.0-4.0
-INRs >5 avoided d/t risk of bleed
Treatment Approach to A. Fib - ANS ✓3 Elements:
1) Rate control
2) Restoration and maintenance of sinus rhythm (if indicated)
3) Stroke prevention
-Goal is to alleviate sxs and improve QOL
Rhythm Control - ANS ✓Focus on restoration of sinus rhythm:
-Palpitations
-SOB
-Dizziness/Lightheadedness
-Activity intolerance
Prevention of tachycardia-induced cardiomyopathy
Prevention of hemodynamic compromise r/t A.Fib
Rhythm Control Treatment - ANS ✓Specific tx type depends on
several factors:
-Heart disease w/LVH or depressed LVEF
-HF
-Age
-Underlying sinus node dysfunction
-Other arrhythmias (e.g. a. flutter)
-Underlying QT prolongation
-Renal function
Note: pts w/a CHADS2VASc2 score of zero who opt for a rhythm
control strategy may be considered to stop OAC
Pharmacologic Management of A. Fib - ANS ✓Class 1: Na+ channel
blockers, Quinidine, Procainamide, Disopyramide, Lidocaine,
Mexilitine, Flecainide, Propafenone
Class 2: Beta Blockers
NU665D
NU665D
NU665D/ NU 665D | Primary Care Adult
Woman II | Qs & As| Grade A| 100%
Correct |(2025/ 2026 Update) Regis
A. Fib Patient Evaluation - ANS ✓-PE: Heart sounds
-EKG- LA dilation?
-TFTs: should be done during initial discovery/change in
condition (e.g. difficult to control rate)
-Electrolytes with Magnesium
-BUN/Creatinine (helpful when trying to decide if AAD or OAC)
-Echocardiogram: valvular disease or reduced LVEF
-Ambulatory monitoring: Holter
Stroke Risk in A.Fib - ANS ✓Thromboembolism: primary
morbidity assoc. w/ A.Fib. Thrombus formation and dislodgement
from left atrial appendage (LAA)
-Based on clinical risk factors and NOT on freq/duration of A.Fib
-Non-valvular meaning A. Fib presumably not r/t mitral valve
heart disease, specifically mitral stenosis
-In general ~48hrs for clot formation; if duration known to be
<48hrs, can cardiovert w/o AC
-Second option: transesophageal echo to confirm absence of LAA
thrombus
-Risk of thrombus is increased in first 3-4 weeks after DCCV,
when gradual return of atrial mechanical function can result in
high risk for thrombus
CHADS 2 - ANS ✓CHF (1)
HTN (1)
NU665D
, 2
NU665D
Age >75 (1)
DM (1)
Prior Stroke (2)
CHADS 2 VASC 2 - ANS ✓CHF (1)
HTN (1)
Age >75 (2)
DM (1)
Prior Stroke (2)
Vascular disease (1)
Age 65-74 (1)
Female (1)
If score >2, oral anticoagulants (or if non valvular A. Fib for prior
stoke, TIA)
If pt has nonvalvular A. Fib and CHADS2VASc2 score of 0,
reasonable to omit anticoag therapy
New Anticoagulants - ANS ✓-3 currently approved
-Tested against coumadin
-No sign. diff b/w the three of them except for S/Es
-Avoid potent Pgp inducers (rifampin, carbemazepine, phehytoin,
phenobarb, St. John's wort) as will decrease effect
-Riva and Apixa: Avoid potent inhibitors of CYP3A4 and Pgp
(Azoles, Protease inhibitors, mycins), as will INCREASE AC effect
Eliquis (apixaban) - ANS ✓Dose: 5mg BID
Renal adjustment: 2.5mg twice daily, must have 2 or more of the
following: Age >80yo, Body wt </= 60kg, Serum creatinine >/=
1.5mg/dL
Half life: 12 hours
Time to Peak: 3-4hours
Direct factor Xa inhibitor
NU665D
, 3
NU665D
Xarelto (rivaroxaban) - ANS ✓Dose: 20mg daily w/evening meal
of at least 500 calories for absorption
Renal Adjustment: CrCl 15-50mg once daily w/evening meal; CrCl
<15mL/min: avoid use
Half life: 5-13 hours
Peak: 2-4 hours
Director Factor Xa inhibitor
Pradaxa (dabigatran) - ANS ✓Dose: 150mg BID
Renal adjustment: 75mg BID; not adequately studied
>10% pts have GI distress
Half life: 12-17hours, Up to 28hours w/renal impairment
Peak: 1-2hours
Direct thrombin inhibitor
Coumadin - ANS ✓-Obtain baseline PT/INR and investigate if
abnormal
-Determine use of potential warfarin interactions (meds)
-Document target INR and RX warfarin tablet strength
-Provide pt edu on safety, monitoring, food and drug interactions
-Recommend 1st INR check on day 3-4
Coumadin Initiation - ANS ✓Day 1-3, initial dose: 5mg (10mg)
Day 3-4:
-1.0-1.3 Dose 7.5mg
-1.4-1.5 Dose 5mg
-1.6-1.8 Dose 5/2.5mg alternating dose
->1.0 Dose 2.5mg
->2.0 hold x1 day, then 2.5mg
Reversal agents: Vitamin K 1-10mg IV/PO (not SQ/IM); Takes 6
(IV) to 25 (PO) hours to reverse warfarin
INR interpretation - ANS ✓-No anticoagulation therapy level:
should be ~1.0
NU665D
, 4
NU665D
-Higher the number, greater risk of bleeding
-Anticoagulation therapy target level: 2.0-4.0
-INRs >5 avoided d/t risk of bleed
Treatment Approach to A. Fib - ANS ✓3 Elements:
1) Rate control
2) Restoration and maintenance of sinus rhythm (if indicated)
3) Stroke prevention
-Goal is to alleviate sxs and improve QOL
Rhythm Control - ANS ✓Focus on restoration of sinus rhythm:
-Palpitations
-SOB
-Dizziness/Lightheadedness
-Activity intolerance
Prevention of tachycardia-induced cardiomyopathy
Prevention of hemodynamic compromise r/t A.Fib
Rhythm Control Treatment - ANS ✓Specific tx type depends on
several factors:
-Heart disease w/LVH or depressed LVEF
-HF
-Age
-Underlying sinus node dysfunction
-Other arrhythmias (e.g. a. flutter)
-Underlying QT prolongation
-Renal function
Note: pts w/a CHADS2VASc2 score of zero who opt for a rhythm
control strategy may be considered to stop OAC
Pharmacologic Management of A. Fib - ANS ✓Class 1: Na+ channel
blockers, Quinidine, Procainamide, Disopyramide, Lidocaine,
Mexilitine, Flecainide, Propafenone
Class 2: Beta Blockers
NU665D
