Intern Case Report Scott Le, DO 11/14/14

Initial Presentation 71 year old male with a 5 day history of shortness of breath and palpitations Outlying facility found A-fib with RVR between 130-150 bpm Rate controlled with diltiazem and transferred No PMH, only on ASA 81 mg

Initial Presentation PSH: Hernia repair, tonsillectomy FH: Brother and sister with A-fib, DLD, HTN; father with heart disease SH: Pipe smoker for 60 years Allergies: NKDA Meds: ASA 81 mg PO daily

Physical Exam Glu 120 Na 135 K 4.3 Cl 99 CO2 28 BUN 11 Cr 0.8 WBC 8.2 Hgb 15.1 Plt 184 total protein 7.3 albumin 4.6 Ca 9.6 total bili 1.5 AST 52 ALT 50 Alk phos 65 BNP 348.0 trop neg UA neg T 98 °F P 102 R 20 BP 128/81 SpO2 95% Eyes: Could not abduct left eye past midline Cardiac: Irregularly irregular, no murmurs, no JVD Lungs: CTAB Ext: No edema

Physical Exam CXR: Bilateral pleural effusions EKG Glu 99 Na 136 K 4.1 Cl 105 CO2 23 BUN 14 Cr 0.82 WBC 6.5 Hgb 13.5 Plt 175 total protein 6 albumin 3.8 Ca 9.1 total bili 1.3 AST 38 ALT 37 Alk phos 68 BNP 689.5 TSH 5.69 T4 1.45 T3 2.8 CXR: Bilateral pleural effusions EKG

Plan Telemetry Metoprolol 25 mg PO BID EP Consult Heparin drip ECHO EF 35-40% with moderate to severe diastolic dysfunction

Discharge Metoprolol 100 mg PO BID Lisinopril 5 mg PO daily Rivaroxaban 20 mg PO daily Follow with EP in 3 weeks for possible cardioversion

Bounce Back! Worsening shortness of breath Lower extremity edema, scrotal edema Palpitations T 97.2, P 90, R 18, BP 111/88, SpO2 95% on 4L nasal cannula Lungs: Diffuse rales Cardiac: Irregularly irregular, no JVD CXR: Worsening bilateral pleural effusions EKG: A-fib

Labs Glu 83 Na 115 K 6.1 Cl 87 HCO3 13 BUN 28 Cr 1.24 Alk Phos 104 AST 1497 ALT 1192 Total Bili 2.7 BNP 874.8 Glu 86 Na 116 K 4.9 Cl 86 HCO3 19 BUN 26 Cr 0.99 Alk Phos 91 AST 2001 ALT 1585 Total Bili 1.8 INR 15.5

Hyponatremia Hypovolemic Euvolemic Hypervolemic Renal vs extrarenal losses Euvolemic SIADH vs primary polydipsia Hypervolemic CHF Cirrhosis Renal Failure Urine Na < 20 FENA: 0.2%

Elevated Liver Enzymes Cholestasis Hepatocellular Viral Autoimmune NASH Vascular Hereditary Drugs/Toxins

Rivaroxaban Factor Xa inhibitor Metabolized through the liver Bound to albumin Falsely elevated INR Daily dosing No monitoring Fewer interactions

Rivaroxabanned? No reversibility Increased risk of GI bleeds? Expensive No monitoring

References http://www.nuclearcardiologyseminars.net/images/afib.jpg http://medsfacts.com/study-XARELTO-causing-HYPONATRAEMIA.php Caldeira, D. et al. Risk of drug-induced liver injury with the new oral anticoagulants: systemic review and meta-analysis. Heart 2014; 100: 550-556. Goljan, ER and Sloka, KI. Rapid review: Laboratory Testing in Clinical Medicine. Philadelphia 2008. Holster, L et al. New Oral Anticoagulants Increase Risk for Gastrointestinal Bleeding: A Systematic Review and Meta-analysis. Gastroenterology 2013; 145: 105-112. Sabatine, MS, et al. Pocket Medicine, 4th Edition. Philadelphia 2011. Stefan, R et al. Rivaroxaban postmarketing risk of liver injury. Journal of Hepatology 2014; 16: 293-300. Zalawadiya SK, et al. Unique case of presumed lisinopril-induced hepatotoxicity. American Journal of Health-System Pharmacy 2010; August 15; 67 (16): 1354-1356.