Managing Atrial Fibrillation and Stroke Risk in Elderly Patients

Atrial fibrillation causing cerebral embolism?

My grandmother at home is 96 years old and has symptoms of hypertension, for which she is taking antihypertensive medication.
In early June, she suddenly experienced slurred speech and weakness in one side of her limbs.
Unfortunately, she was not taken to the hospital within the critical four-hour window, but a CT scan showed no bleeding.
Therefore, the emergency physician only administered four doses of antiplatelet medication.
That day, her condition improved; she was able to speak and move her limbs.
Afterward, she took one dose of antiplatelet medication daily for a month, but she occasionally experienced slurred speech or weakness in her limbs.
In early July, she returned to the neurology clinic, where the doctor recommended switching her medication to Amlodipine 2.5 mg once in the morning and once at night, and changing her antiarrhythmic medication to Concor 1.25 mg.
There were no particular issues during the medication switch, and her blood pressure was normal.
However, the next morning, her blood pressure dropped to 80/40, and her heart rate was 38, prompting an emergency visit.
She was treated with IV fluids, and the doctor indicated that Concor might be a long-acting medication, so it was changed to Inderal, a short-acting medication, at half a tablet.
She has been on this regimen since then.
Currently, she has started experiencing soft stools or diarrhea, which has persisted for over a week.
I would like to know if this could indicate an overdose of Amlodipine and whether it would be appropriate to reduce the dosage to 1.25 mg, taking half a tablet in the morning and half in the evening.

The second issue is that her heart rate occasionally spikes above 150 beats per minute for two to three days each week, while her systolic blood pressure remains low at around 105.
Taking Inderal causes her blood pressure to drop to 80-90, which leads to confusion.
Is there a medication specifically for treating tachycardia without lowering blood pressure?
Lastly, the patient has a history of chronic hypertension (170-130/100-80), but after taking Amlodipine for over a month, her blood pressure has significantly decreased, generally ranging from 110-100/80-70.
What could be the mechanism behind this change?

Lin Xiansheng, 30~39 year old female. Ask Date: 2022/08/14

Dr. Chen Jili reply Cardiology

I suggest that you discuss the above situation with your grandmother's attending physician to see if further examinations are necessary.
Thank you, and wish you good health!

Reply Date: 2022/08/14

More Info

Managing atrial fibrillation (AF) and stroke risk in elderly patients, particularly those with comorbidities such as hypertension, is a complex and nuanced process. In the case of your grandmother, who is 96 years old and has a history of hypertension, the management of her condition requires careful consideration of her age, overall health, and the medications she is currently taking.

Atrial fibrillation is a common arrhythmia in the elderly and is associated with an increased risk of stroke. The risk of stroke in patients with AF is often assessed using the CHA2DS2-VASc score, which takes into account factors such as congestive heart failure, hypertension, age, diabetes, prior stroke or transient ischemic attack (TIA), vascular disease, and sex. Given your grandmother's age and history of hypertension, she may be at a higher risk for stroke, which necessitates anticoagulation therapy to reduce this risk.

In your grandmother's case, it appears that she was initially treated with a medication called 保栓通 (likely a form of antiplatelet or anticoagulant), which is appropriate for stroke prevention. However, the subsequent change to艾必克 (Amlodipine) and康肯 (Dronedarone) raises some concerns. Amlodipine is primarily a calcium channel blocker used for hypertension and angina, while Dronedarone is used to manage AF. The combination of these medications can sometimes lead to hypotension (low blood pressure) and bradycardia (slow heart rate), especially in elderly patients who may have altered pharmacokinetics and pharmacodynamics.

The episodes of low blood pressure (80/40 mmHg) and bradycardia (heart rate of 38 bpm) that your grandmother experienced are concerning and suggest that the current medication regimen may need to be reevaluated. It is crucial to monitor her blood pressure and heart rate closely, especially after any medication changes. The fact that she experienced a significant drop in blood pressure after switching to Amlodipine indicates that this medication may not be suitable for her at the current dosage or in combination with her other medications.

Regarding her symptoms of diarrhea and soft stools, it is possible that these could be side effects of the medications she is taking, particularly if there has been a recent change in dosage or medication. It is essential to discuss these symptoms with her healthcare provider, as they may need to adjust her medications accordingly.

In terms of managing her episodes of tachycardia (heart rate exceeding 150 bpm), it is important to find a medication that can effectively control her heart rate without causing significant drops in blood pressure. Beta-blockers, such as Inderal (Propranolol), can be effective for rate control in AF, but they may also lower blood pressure. Your grandmother's healthcare provider may consider adjusting the dosage or exploring other options, such as a different class of antiarrhythmic medications that can help control heart rate without significantly affecting blood pressure.

Finally, the observed decrease in blood pressure after starting Amlodipine could be attributed to its vasodilatory effects, which lower systemic vascular resistance and, consequently, blood pressure. This is particularly relevant in elderly patients, who may be more sensitive to the effects of antihypertensive medications.

In summary, managing atrial fibrillation and stroke risk in elderly patients like your grandmother requires a careful balance of medications to control heart rate and blood pressure while minimizing side effects. It is crucial to maintain open communication with her healthcare provider to ensure that her treatment plan is tailored to her specific needs and to address any adverse effects she may be experiencing. Regular follow-up appointments and monitoring of her vital signs will be essential in optimizing her care.

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