23
Management strategies Key points
• Management options discussed included
use of further noninvasive and invasive
diagnostic strategies versus preemptive
arrhythmia therapies as follows:
▶ Prolonged arrhythmia monitoring with
loop recorder insertion
▶ EP testing to assess AV conduction and
evaluate the inducibility of VAs, followed
by CIED insertion
▶ Empiric pacemaker implantation
▶ Empiric transvenous ICD implantation
• Values elicited in discussion included desire
to avoid complications from symptomatic
episodes, most expeditious management
strategy, and focus on quality of life.
• Although several risk indicators for sudden
death were present (PR interval 260
ms and LBBB), the most likely serious
etiology for observed episodes remained
bradyarrhythmias due to high-grade AV
block. Advanced functional impairment
and primary emphasis on quality of life led
to the decision to pursue empiric pacemaker
implantation.
• Age, significant functional
impairment, patient wishes, and
suggestive clinical features were
key points in determining ultimate
management strateg y.
• Transvenous ICD would
accomplish protection against
brady- and tachyarrhythmias,
but limited evidence, possible
longer adjustment (compared to
pacemaker), and patient wishes
favored pacemaker implantation.
• Management options discussed included
prescribing direct oral anticoagulant/
warfarin, left atrial appendage occlusion, and
avoidance of anticoagulation altogether.
• Values elicited in discussion included
reduced though acceptable quality of life,
desire to avoid preventable life-threatening/
life-altering medical complications,
preference for noninvasive therapy, increased
thromboembolic risk balanced by limited
bleeding risk using conventional risk
calculators, and limited fall risk given bed-
confined status.
• With CHA
2
DS
2
-VASc and HAS-BLED
risk scores of 3 and 2, respectively, oral
anticoagulation was recommended and
accepted.
• Conventional risk calculators are
recommended for use in DM1
patients and support the use of oral
anticoagulation here.
• Fall risk and frailty are difficult to
quantify but must be considered
when considering anticoagulation.
• Patient wishes to avoid serious
preventable complications through
noninvasive means were heeded;
anticoagulation will reduce the risk
of systemic thromboembolism due
to AF.
