A 72-year-old woman with a history of hypertension and coronary artery disease was admitted to the hospital 2 months ago with dizziness and palpitations. The patient was diagnosed with persistent atrial fibrillation but has been doing well since. She takes 20-minute walks on most days of the week for exercise with no chest pain or shortness of breath.
The patient had coronary artery bypass graft surgery 7 years ago for stable angina and also has gastroesophageal reflux disease, right knee osteoarthritis, and chronic constipation. Her current medications include aspirin, metoprolol, digoxin, simvastatin, warfarin, and valsartan. She also takes antacids frequently for heartburn and upper abdominal discomfort.
Her blood pressure is 146/80 mm Hg, and pulse is 76/min and irregularly irregular. BMI is 31 kg/m². A faint ejection-type systolic murmur is heard at the right upper sternal border. Her peripheral pulses are 2+ and there is trace edema in the leg with the vein harvest scar.
Laboratory results are as follows:

Her last echocardiogram showed normal left ventricular systolic function and mild mitral regurgitation.
Compared to warfarin, dabigatran has a lower risk of which of the following?

Question

A 72-year-old woman with a history of hypertension and coronary artery disease was admitted to the hospital 2 months ago with dizziness and palpitations. The patient was diagnosed with persistent atrial fibrillation but has been doing well since. She takes 20-minute walks on most days of the week for exercise with no chest pain or shortness of breath.
The patient had coronary artery bypass graft surgery 7 years ago for stable angina and also has gastroesophageal reflux disease, right knee osteoarthritis, and chronic constipation. Her current medications include aspirin, metoprolol, digoxin, simvastatin, warfarin, and valsartan. She also takes antacids frequently for heartburn and upper abdominal discomfort.
Her blood pressure is 146/80 mm Hg, and pulse is 76/min and irregularly irregular. BMI is 31 kg/m². A faint ejection-type systolic murmur is heard at the right upper sternal border. Her peripheral pulses are 2+ and there is trace edema in the leg with the vein harvest scar.
Laboratory results are as follows:

Her last echocardiogram showed normal left ventricular systolic function and mild mitral regurgitation.
Compared to warfarin, dabigatran has a lower risk of which of the following?

Quizplus · Accepted Answer

11ec193a_96b7_5f6b_853d_55a71040d30e_MD0002_00 Systemic thromboembolism is a major cause of long-term morbidity in patients with atrial fibrillation. Treatment with warfarin or target-specific oral anticoagulants (TSOACs: dabigatran, rivaroxaban, apixaban, edoxaban) has been shown to significantly reduce the risk of embolization in patients at moderate to high risk for thromboembolic events. Dabigatran is an oral direct thrombin inhibitor that decreases the risk of thromboembolic events in patients with nonvalvular atrial fibrillation. thromboembolic events direct thrombin inhibitor In randomized controlled trials, anticoagulation with TSOACs has shown lower rates of both ischemic stroke and major bleeding compared to warfarin. More importantly, their use is associated with a significant reduction in the risk of hemorrhagic stroke and/or intracranial bleeding, as well as all-cause mortality. However, they are not recommended for use in certain patient subsets, including: Patients with renal failure (CrCl <30 mL/min) or end-stage renal diseasePatients with valvular heart disease (mitral stenosis, prosthetic heart valves, severe decompensated valvular disease likely to require valve replacement)Pregnant patients Patients with renal failure (CrCl <30 mL/min) or end-stage renal disease < Patients with valvular heart disease (mitral stenosis, prosthetic heart valves, severe decompensated valvular disease likely to require valve replacement) Pregnant patients (Choice A) There is no reported change in the incidence of congestive heart failure in patients treated with dabigatran compared to warfarin. (Choice B) Dyspepsia is reported more frequently in patients taking dabigatran compared to those on warfarin, and is a frequent cause of nonadherence to therapy. (Choice D) Neither TSOACs nor warfarin is associated with an increased risk of pericarditis. However, anticoagulants should be used with caution in patients with pericarditis as both TSOACs and warfarin have been associated with hemorrhagic transformation. (Choice E) There was a slightly increased risk of myocardial infarction in patients taking dabigatran compared to warfarin. Educational objective: In patients with nonvalvular atrial fibrillation, anticoagulation with target-specific oral anticoagulants is associated with a lower risk of intracranial hemorrhage when compared to warfarin. __________ References: Dabigatran versus warfarin in patients with atrial fibrillation. (http://www.ncbi.nlm.nih.gov/pubmed/19717844) 2014 AHA/ACC/HRS Guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart rhythm Society. (http://www.ncbi.nlm.nih.gov/pubmed/24682347)

A 72-Year-Old Woman with a History of Hypertension and Coronary