Atrial Fibrillation in Heart Failure Managed with Warfarin and Digoxin and Complicated by Hemorrhagic and Thrombotic Events: A Case Report from a Rural Kenyan Hospital

Atrial fibrillation (AF) is the most common supraventricular tachyarrhythmia and is characterized clinically by irregular palpitations, dizziness, presyncope and syncope, effort intolerance, an apical-radial pulse deficit, and heart failure. The diagnosis is confirmed by an electrocardiogram showing an irregularly irregular ventricular rhythm, absent P waves, and the presence of fibrillatory waves. In Sub-Saharan Africa, the prevalence of AF is about 4.3% and 0.7% in individuals aged ≥40 years and aged ≥70 years, respectively, while the main risk factors for AF are hypertension, cardiomyopathy, and rheumatic heart disease. Rate control using beta blockers, the use of antiarrhythmics, anticoagulation using warfarin or direct oral anticoagulants to prevent stroke, cardiovascular risk factor reduction, and radiofrequency catheter ablation in select patients are the main objectives in the management of AF as per the current guidelines by the European Society of Cardiology (ESC), the American Heart Association (AHA), the American College of Cardiology (ACC), etc. This case report highlights the challenges of managing AF in congestive heart failure (CHF) in a rural Kenyan hospital in which the patient had hemorrhagic complications from warfarin toxicity followed by stroke after warfarin withdrawal and the therapeutic effects of adding digoxin to achieve better rate control and improve the CHF morbidity.