A 58-year-old man is preparing for discharge from the cardiac intensive care unit. He was admitted 4 days ago for ventricular tachycardia storm, experiencing multiple recurrent implantable cardioverter-defibrillator (ICD) shocks. He was stabilized on an intravenous amiodarone infusion and is now being transitioned to an oral amiodarone loading regimen (400 mg three times daily) to suppress further arrhythmias.
His past medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of 20%, permanent atrial fibrillation, mechanical mitral valve replacement 5 years ago, and stable chronic kidney disease.
His home medications, which were continued throughout his hospitalization, include warfarin 5 mg daily, digoxin 0.125 mg daily, metoprolol succinate 100 mg daily, lisinopril 20 mg daily, and furosemide 40 mg daily.
Today's laboratory results are as follows:
| Laboratory Test | Result | Reference / Target |
|---|---|---|
| Serum creatinine | 1.7 mg/dL | Baseline 1.6 mg/dL |
| Serum potassium | 4.2 mEq/L | 3.5 - 5.0 mEq/L |
| INR | 3.1 | 2.5 - 3.5 |
| Serum digoxin | 0.8 ng/mL | 0.5 - 0.9 ng/mL |
Which of the following is the most appropriate next step in treatment adaptation and monitoring for this patient at discharge?
- Reduce both the warfarin and digoxin doses by 30% to 50%, and schedule a follow-up for INR and serum digoxin level checks in 3 to 7 days.Cevap
- BMaintain the current doses of all medications, schedule an INR check in 14 days, and advise the patient to return if palpitations recur.
- CDiscontinue warfarin, initiate a direct oral anticoagulant, reduce the digoxin dose by 50%, and schedule a follow-up in 1 week.
- DReduce the warfarin dose by 30% to 50%, maintain the digoxin dose, and order an anti-factor Xa activity assay in 5 days to monitor the anticoagulant effect.
- EDiscontinue lisinopril and furosemide due to the recent rise in serum creatinine, maintain the warfarin and digoxin doses, and recheck a basic metabolic panel in 24 hours.