Arrhythmias and Conduction Disease — Viva Defence

Opening statement (SASPOP, delivered aloud)

"Mrs Ford is an 82-year-old retired teacher with persistent atrial fibrillation on a background of hypertension and stage 3 chronic kidney disease, presenting with worsening exertional breathlessness. Her main problems are: persistent AF with inadequate rate control and high stroke risk — her CHA₂DS₂-VASc is at least 4; anticoagulation complicated by CKD and a falls history; hypertensive heart disease as a likely driver; and her goals — remaining independent at home. I would like to reassess her rate control, defend her anticoagulation choice against her renal function and falls, and address her breathlessness systematically." [1]

Structured problem list

1. Persistent AF with high stroke risk — CHA₂DS₂-VASc at least 4 (age 75 or older scores 2, hypertension 1, female sex 1); anticoagulation is indicated by any guideline interpretation [1].
2. Anticoagulation complexity — creatinine clearance 34 mL/min drives DOAC dose selection and rules out poorly renally-cleared agents; the falls history is a perceived, not absolute, barrier [2] [3].
3. Breathlessness with exertion — the differential is rate-related, hypertensive heart disease with preserved or reduced ejection fraction, ischaemia, anaemia, or a drug effect; it needs a structural and functional answer before the rhythm strategy is finalised.
4. Falls and frailty — two falls in a year demand a falls workup in their own right: postural hypotension, medication review, vision, strength and balance, bone protection [2].

Integrated management plan

• Characterise the AF burden and rate: 12-lead ECG, ambulatory monitor for rate profile over 24 hours, and a symptom correlation — then set a lenient rate target, resting rate under 110 per RACE II, because strict targets buy drug toxicity without outcome benefit in a minimally symptomatic patient [5].
• Choose the rate-control agent against her phenotype: a beta-blocker if tolerated and no contraindication; digoxin is a defensible alternative or adjunct in a sedentary elderly patient — RATE-AF showed digoxin achieved similar patient-reported outcomes to bisoprolol with fewer adverse effects in an elderly AF cohort [6].
• Anticoagulate with dose precision: apixaban with attention to its dose-reduction criteria (age, weight, creatinine), given its favourable renal and bleeding profile in ARISTOTLE; avoid full-dose renally cleared DOACs at this creatinine clearance [3].
• Treat the falls as a modifiable bleeding risk, not a contraindication: HAS-BLED is a checklist — control the blood pressure, remove interacting drugs and sedatives, address alcohol, and refer for strength-and-balance work — while quantifying her stroke risk honestly: at her score, the annual stroke risk outweighs the modelled subdural risk from all but the most extreme falls [2] [1].
• Investigate the breathlessness on its own merits: echocardiogram for ventricular function and valve disease, BNP, full blood count and iron, and ischaemic assessment if the picture fits — the result decides whether an early rhythm-control strategy, which EAST-AFNET 4 supports in recently diagnosed AF with cardiovascular comorbidity, has a role even at 82 [4].

Probing questions with model answers

"Her daughter says the blood thinner will kill her if she falls again. What do you say?" — "I would acknowledge the fear, then quantify: at a CHA₂DS₂-VASc of 4 her untreated stroke risk is substantial every year, and modelled analyses show a patient must fall extremely frequently for subdural risk to outweigh that benefit. My job is not to withhold anticoagulation but to reduce what can be reduced — blood pressure, interacting drugs, sedatives, and the falls themselves — and to choose the agent with the best bleeding and renal profile for her. I would document the shared decision and review it." [1] [2] [3]

"Why apixaban and not warfarin — or dabigatran?" — "For non-valvular AF the DOACs are preferred, and ARISTOTLE showed apixaban reduced stroke, major bleeding and mortality versus warfarin. At a creatinine clearance of 34, apixaban's limited renal clearance makes it the most defensible DOAC; dabigatran is predominantly renally cleared and accumulates at this level, and warfarin is reserved for mechanical valves and significant mitral stenosis — while carrying more intracranial bleeding." [3]

"Would you cardiovert her?" — "Not reflexively. She is elderly with persistent AF and CKD; my default is rate control with a lenient target. But I would not be dogmatic — EAST-AFNET 4 showed early rhythm control improves cardiovascular outcomes in recently diagnosed AF with comorbidity, and if her breathlessness proved to be tachycardia- or rhythm-driven I would discuss cardioversion or ablation with her, framed by frailty and recurrence risk rather than by age alone." [4] [5]

"What rate target do you accept, and why?" — "A resting rate under 110, per RACE II — lenient control was non-inferior to strict control for the composite clinical outcome, with fewer drugs and fewer side effects. I escalate only for symptoms or a falling ejection fraction, not for a number." [5]

"She asks whether she can stop the tablets once she feels better." — "Anticoagulation does not depend on symptoms or on whether the AF is currently felt — stroke risk follows the score, and it persists in sinus rhythm after cardioversion or ablation. Feeling better is the goal of rate control; the anticoagulant is there for the strokes she will never feel coming." [1]

Communication points

• Use absolute annual risk language — "out of 100 people like you" — rather than relative percentages when discussing stroke and bleeding [1].
• Frame HAS-BLED aloud as a fix-list: blood pressure, interacting medications, alcohol, falls prevention — this reassures rather than alarms [2].
• Document the shared decision and the review interval; anticoagulation decisions in multimorbidity are living decisions, not one-off orders [3].