Comorbid hypertension and new-onset atrial fibrillation.

Background

An adult patient (we will use the placeholder name L.) had been established at the practice for two years prior to this episode. L. is in their early sixties, works full-time at the Hudson River Maritime Museum as the collections manager, and has a relevant past medical history of essential hypertension (diagnosed 2019), hyperlipidemia, and obstructive sleep apnea managed with CPAP since 2021. Family history is significant for paternal myocardial infarction at age 57.

At the September 2024 annual visit, BP averaged 152/96 mmHg over three readings despite reported adherence to lisinopril 40 mg daily and amlodipine 10 mg daily. Routine ECG, performed because of an isolated complaint of "fluttering" once weekly over the prior month, showed atrial fibrillation with a controlled ventricular response of 88 bpm. This was a new finding; the prior ECG eight months earlier had been normal sinus.

Decision points

1. Initial workup and risk stratification

L. was in the office. We sent for a TSH (normal), a basic metabolic panel and CBC (normal), and a transthoracic echocardiogram at Quest Imaging (returned in 6 days: LVEF 55%, mild left atrial enlargement, no valvular disease). CHA₂DS₂-VASc score on the day was 3 (age 65–74 inferred at next birthday, hypertension, prior TIA history that was elicited on careful re-history — a TIA at age 58 that had not previously been documented in our chart).^[01]

2. Anticoagulation

We initiated apixaban 5 mg twice daily based on a CHA₂DS₂-VASc score of 3 and HAS-BLED of 1 (age alone), with shared decision-making documented in the chart and a printed copy of the ACC/AHA shared-decision tool printed for L. Pharmacy benefits checked at Kingston CVS; copay $30/month; we also coordinated a co-pay assistance card through the manufacturer for the first three months while L.'s deductible reset.

3. Cardiology coordination

L. was referred to the Westchester Medical Center Cardiology service, with appointment available within 14 days through their cardiology direct-referral line. The cardiology consult letter back to us recommended a rate-control strategy with metoprolol succinate 50 mg daily and re-evaluation in 90 days.

4. Hypertension recalibration and deprescribing

L.'s BP remained elevated despite the addition of metoprolol succinate. Home BP monitoring (with a validated cuff per AHA recommendations) showed mean BP of 148/92 mmHg over two weeks. We added chlorthalidone 12.5 mg, intentionally choosing chlorthalidone over hydrochlorothiazide on the strength of Roush et al, 2015.^[02] At the next visit, BP was 132/82.

In month four we conducted a deliberate medication-reconciliation visit. L. had been taking, over the years, a regimen accreted from three prior practices: lisinopril, amlodipine, metoprolol, chlorthalidone, atorvastatin, aspirin 81 mg, omeprazole, and a multivitamin. The aspirin had been on the list for primary prevention since age 55; per the USPSTF 2022 update, aspirin for primary prevention was now a D recommendation in adults 60+. We discontinued aspirin (with anticoagulation already on board this was independently appropriate). Omeprazole had been started for transient reflux in 2018 and had been continued indefinitely; we tapered per the Bruyère PPI deprescribing algorithm.^[03] The amlodipine was reduced from 10 to 5 mg as BP was now well-controlled.

5. Rhythm control and the return to sinus

At the 6-month cardiology follow-up, L. remained in atrial fibrillation. Cardiology proceeded with a single direct-current cardioversion in month 8, after a TEE confirmed the absence of left atrial appendage thrombus. L. converted and remained in sinus rhythm at the 11-month follow-up. Apixaban continued.

Outcome

At the 14-month visit (last visit of this case-log period): BP 124/76 averaged over a two-week home log; HR 68 in sinus rhythm; LVEF unchanged at 55%; HbA1c 5.4 (no T2DM diagnosis); on apixaban, lisinopril 20, amlodipine 5, metoprolol succinate 50, chlorthalidone 12.5, atorvastatin 40. The medication count went from eight to six.

L. has continued to work full-time at the Maritime Museum throughout the period and reports no functional limitation.

What we got wrong

The TIA at age 58 had been mentioned at the original 2022 establishment visit and was not entered as a problem on the chart. The CHA₂DS₂-VASc score in our chart had been calculated at 1 for two years rather than the appropriate 2; if L. had developed AF before this point, our pre-anticoagulation calculation would have understated risk. The error was discovered during the careful re-history at the 2024 visit. The chart is now corrected; we have additionally instituted a medical-assistant intake-script change that asks specifically for any history of stroke, TIA, transient neurological event, or "ministroke" at every annual visit, regardless of prior chart contents.