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

2. 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 bpm
Rate controlled with diltiazem and transferred
No PMH, only on ASA 81 mg

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. 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

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

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

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

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

14. References http://www.nuclearcardiologyseminars.net/images/afib.jpg
Caldeira, D. et al. Risk of drug-induced liver injury with the new oral anticoagulants: systemic review and meta-analysis. Heart 2014; 100:
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:
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:
Zalawadiya SK, et al. Unique case of presumed lisinopril-induced hepatotoxicity. American Journal of Health-System Pharmacy 2010; August 15; 67 (16):