Atrial Fibrillation, Heart Failure, CKD, and Falls

His CHA2DS2-VASc score is 5, so he has a high stroke risk and should be anticoagulated unless there is a compelling reason not to. Falls alone are not a contraindication; the annual risk of a major bleed from a fall is lower than the stroke risk in this population, especially when the falls are addressed. I would choose apixaban because it has the most favorable bleeding profile in older patients and CKD, and it does not require INR monitoring. His dose would be 5 mg twice daily because he meets only one dose-reduction criterion (creatinine 1.6 mg/dL); he is 76 years old and weighs 102 kg. I would not reduce the dose to 2.5 mg without two criteria, because underdosing increases stroke risk. I would avoid dabigatran given his CKD and fall risk, and I would not use warfarin unless there is a reason. I would address modifiable fall risks: vision, gait and balance, home hazards, and review of sedating medications. I would document a shared decision that includes his fear of falling and the stroke prevention benefit.

He is symptomatic with a rate of 118/min, but he is hemodynamically stable. I would use a beta-blocker, preferably carvedilol, and titrate cautiously because of his heart failure with reduced ejection fraction; I would not use verapamil or diltiazem because they are negative inotropes and can worsen heart failure. I would assess volume status and continue diuretic therapy if congested. If his rate remains high, digoxin could be considered, but his CKD requires renal dose adjustment and monitoring for toxicity, especially given his fall risk and possible electrolyte shifts. I would check TSH, electrolytes, and magnesium, and I would treat reversible triggers. If he remains symptomatic despite rate control, I would consider rhythm control with amiodarone or referral for ablation, but I would not start amiodarone without a plan for monitoring. I would also address his falls with physical therapy and home safety, because anticoagulation and rate-control decisions depend on his overall function and goals.

I would stop apixaban and resuscitate with IV fluids and blood products as needed. He has a major gastrointestinal bleed, so I would activate the GI bleed pathway, obtain type and screen, and arrange urgent endoscopy. For reversal, if apixaban was taken within a few hours, activated charcoal may be considered if he is alert and protected. For life-threatening bleeding, andexanet alfa is the specific agent; if it is unavailable, four-factor prothrombin complex concentrate is an alternative. Fresh frozen plasma is not a reliable reversal agent for apixaban, and vitamin K does not reverse it. I would avoid NSAIDs and consider a proton pump inhibitor. Restarting anticoagulation is a judgment call: his stroke risk remains high, so I would generally restart after hemostasis is achieved, often within 7–14 days, in consultation with cardiology and gastroenterology. I would document the risk-benefit discussion and involve the patient in the decision.