How Should We Apply AT9 to this Patient?

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AB is a 64 year old man with a past medical history of hypertension, diabetes, and ischemic cardiomyopathy.  He presented to his cardiologist, Dr. Smith, 6 months ago with palpitations associated with shortness of breath and dizziness and was diagnosed with atrial fibrillation.  He has been on warfarin therapy with a goal INR of 2-3 since that time.  Today he presents to anticoagulation clinic for routine follow-up and states, “I just can’t keep coming to appointments every 4 weeks like this anymore! My work really won’t allow me to be gone this much.”

PMH: 
Hypertension
MI 2006
Ischemic cardiomyopathy (last EF 35%)
Diabetes 
GERD
Seizures (none since 2008)

Pertinent Fasting Labs: (2 weeks ago)
SCr: 1.3 mg/dl (stable)
Estimated CrCl: 60.7 ml/min
Glucose: 136 mg/dl
HbA1c: 7.5%
LFTs: WNL

POC INR: (past 6 months)

Date

POC INR

Warfarin Dose

Dose Changes

3/11

2.1

5mg daily x 7.5mg on Mon/Fri

 

2/9

2.0

5mg daily x 7.5mg on Mon/Fri

 

1/3

2.2

5mg daily x 7.5mg on Mon/Fri

 

11/28

2.6

5mg daily x 7.5mg on Mon/Fri

 

10/31

3.4

5mg daily x 7.5mg on Mon/Wed/Fri

5mg daily x 7.5mg on Mon/Fri

10/10

3.2

5mg daily x 7.5mg on Mon/Wed/Fri

 

9/26

2.9

5mg daily x 7.5mg on Mon/Wed/Fri

 

9/19

2.0

5mg daily x 7.5mg on Mon/Fri

5mg daily x 7.5mg on Mon/Wed/Fri

9/12

1.7

5mg daily (started 2 weeks ago)

5mg daily x 7.5mg on Mon/Fri

 

Vitals (today):
Wt: 86.5 kg
Ht: 5’ 11”
BMI: 26.5 kg/m2
BP: 119/71 mmHg
HR: 92 bpm

Medications: 
Aspirin 81mg daily
Lisinopril 20mg daily
Simvastatin 40mg daily
Spironolactone 25mg daily
Metoprolol Succinate 200mg daily
Metformin 1000mg twice daily
Glipizide 10mg twice daily
Omeprazole 40mg daily
Phenytoin Sodium 200mg twice daily

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