q12.44 - sami2004

[ArchivalUser]

A 70-year-old retired man is evaluated because of palpitations that have been present for about 10 years but are becoming increasingly more frequent and longer lasting. They are not accompanied by dizziness, presyncope, or syncope. The patient believes that his heart rate is quite rapid during his palpitations, but he does not count his pulse rate.

On physical examination, his pulse rate is 62/min and regular, and his blood pressure is 148/74 mm Hg. The remainder of the examination is normal. A chest radiograph is normal. An electrocardiogram shows prominent QRS voltage and a suggestion of a left atrial abnormality. A transthoracic echocardiogram is normal. Thyroid function studies are normal, and 24-hour Holter monitoring is unrevealing. You give the patient an event monitor which, over a 2-month period, documents the presence of paroxysms of atrial fibrillation with ventricular rates ranging between 95 and 190/min.

Which of the following is most appropriate at this time?

(A) Begin adjusted dose warfarin.
(B) Begin aspirin.
© Schedule transesophageal echocardiography.
(D) Begin low-dose warfarin and aspirin.

[ArchivalUser]

CHADS score age 75 and more 2, HTN : 1 = 3 will start warfarin

Answer is A.

Left atrial abnormality ???

[ArchivalUser]

ANSWER IS A

This patient has no documented heart disease and therefore has “lone” paroxysmal atrial fibrillation. He has not had a prior embolism and does not have diabetes mellitus or left ventricular dysfunction. However, he is 70 years old and his risk for embolism is 4% to 5% per year, making anticoagulation with warfarin necessary. Aspirin is less effective than warfarin but more effective than placebo and can be given when warfarin is contraindicated. Adjusted-dose warfarin has been shown to be superior to the combination of warfarin and aspirin or to a fixed small dose of warfarin. Because chronic treatment with warfarin, adjusted to the recommended international normalized ratio of 2.0 to 3.0, will be begun and continued for life, transesophageal echocardiography to assess the presence of atrial thrombus is unnecessary

[ArchivalUser]

htn .
no chf
no dm
no stokr or tia
age

[ArchivalUser]

age is less than 75

so answer should be aspirin

[ArchivalUser]

Yea, I know , confusing.

Aspirin is less effective than warfarin but more effective than placebo and can be given when warfarin is contraindicated.

Actually, this is not lone AF.

Hypertension is score one point.

Lone = no score ,....Asprin
Score 1 & 2, ...intermediate risk, we need to choose bt asprin and warfarin. Because of this age, and risk of embolism, warfarin is preferred. According to guideline, warfarin is more effective than asprin.

So, warfarin is preferred for AF than asprin.

Btw, this is not lone AF.

[ArchivalUser]

htn should be >140/90 so here it is less than that

[ArchivalUser]

and Intermediate risk of thromboembolic event. 2.8% risk of event per year if no coumadin. it is risk on one score..( 1 point)

O point ---1.9% risk of event
1 point ---2.8% risk of event
2 point ---4.0%
3 point--5.9%
4 point---8.5 %
6 point---18.2 %

i am not sure y ans says risk 4-5% only for one point.

[ArchivalUser]

Wow, u figure makes me feel depressed!!

[ArchivalUser]

Score Risk Anticoagulation Therapy Considerations
0 Low Aspirin Aspirin daily
1 Moderate Aspirin or Warfarin Aspirin daily or raise INR to 2.0-3.0, depending on factors such as patient preference
2 or greater Moderate or High Warfarin Raise INR to 2.0-3.0, unless contraindicated (e.g. clinically significant GI bleeding, inability to obtain regular INR screening








http://en.wikipedia.org/wiki/CHADS2_score