| Case study level 3 – Atrial fibrillation
Learning outcomes
Level 3 case study: You will be able to:
- interpret clinical signs and symptoms
- evaluate laboratory data
- evaluate treatment options
- state goals of therapy
- describe a pharmaceutical care plan to include advice to a clinician
- describe the prognosis and long-term complications
- describe the social pharmacy issues which could include supply (e.g. complex treatments at home, concordance and compliance) and lifestyle issues.
Scenario
Mr John Jones (61 years) is admitted to the emergency assessment unit at his local hospital complaining of palpitations, breathlessness and dizziness. He has a 5-day history of some dizziness and palpitations. In the last 24 hours he complained
additionally of shortness of breath. He collapsed at home and was then admitted to hospital via the emergency department.
He experienced similar symptoms two months ago but did not seek medical advice at that time and seemed to recover quickly. On examination and review by the admitting doctor the following information is obtained:
Previous medical history
Hypertension (diagnosed 5 years ago), no previous history of cardiovascular disease. The patient is a regular cigarette smoker (>20 per day) and drinks approximately 20 units of alcohol per week.
Drug history
No known allergies. Mr Jones had been prescribed lisinopril tablets 20 mg once daily but was poorly compliant with treatment.
Signs and symptoms on examination
a. Blood pressure 100/70 mmHg
b. Heart rate 175 bpm, irregular
c. Respiratory rate 25 breaths per minute
d. No basal crackles in the lungs.
Diagnosis
Atrial fibrillation.
Relevant test results
Full blood counts, liver function tests, electrolytes and renal function were all normal at admission and throughout the admission to discharge.
Mr Jones is subsequently transferred to the cardiology ward where his continuing atrial fibrillation is later confirmed as persistent atrial fibrillation. As the ward clinical pharmacist, you are responsible for daily review of drug charts and advice to medical and nursing staff on all aspects of drug treatment for patients on the ward.
Questions
1 What is atrial fibrillation?
2 What are the most common signs and symptoms exhibited by patients with atrial fibrillation? Indicate which of these signs and symptoms the patient is exhibiting.
3 What are the two options in terms of treatment strategy that may be employed to manage atrial fibrillation? Indicate what would be the most appropriate strategy that you could recommend to the doctor managing this patient and why you think this is the case.
4 Assuming a rate control strategy is to be used what class of drug should be the first-line treatment for this patient? If the first-line drug was contraindicated what class of drug could be used as alternative treatment?
5 What patient parameters should be monitored to assess therapy with the usual first-line treatment and what is an appropriate treatment target for such parameters?
6 What are the two options in terms of antithrombotic prophylaxis in this patient and what are the potential side-effects of each? State which of these is the most appropriate for this patient and why.
7 Assuming the patient is to be discharged on a beta-blocker and aspirin, what counselling does he require?
General references
- Clinical Knowledge Summaries (2007) Atrial fibrillation. Available at http://www.prodigy.nhs.uk/atrial_fibrillation [Accessed 3 July 2008].
- Joint Formulary Committee (2008) British National Formulary 55. London: British Medical Association and Royal Pharmaceutical Society of Great Britain, March.
- Kumar P and Clark M (Eds) (2004) Kumar and Clark’s Clinical Medicine, 5th edn. London: Saunders Ltd.
- NICE (National Institute for Health and Clinical Excellence) (2006) Atrial fibrillation. Available at http://www.nice.org.uk/page.aspx?o=cg036quickrefguide [Accessed 3 July 2008].
Author: Narinder Bhalla; BSc (Hons), MSc, MRPharmS. Pharmacist,Cambridge University Hospital
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