Aashi
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A 76-year-old man returns to your clinic for a follow-up appointment after having an echocardiogram and a Holter monitor done. Both test results are normal. The patient has been having sensations of a rapid heartbeat for several years. He describes these episodes as "a strange pounding in my heart" occurring suddenly and ending spontaneously. He has never had syncope, and these episodes are not associated with dyspnea or chest pain.
On physical examination, his pulse is 64/min and regular, and blood pressure is 142/78 mm Hg. The rest of his examination is within normal limits. A repeat EKG shows a normal sinus rhythm, without change from earlier EKGs. An event monitor is put in place. Three months later, you receive a report from the cardiologist that reveals paroxysms of atrial fibrillation with a rapid ventricular response that ends spontaneously.
What is the most appropriate management for this patient's paroxysmal atrial fibrillation at this time?
(A) Begin aspirin 325 mg once a day
(B) Elective cardioversion
(C) Transesophageal echocardiogram
(D) Begin warfarin and adjust the dose based on INR
(E) Send the patient for electrophysiologic testing (EPS)
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"Obstacles are those frightful things you see when you take your EYES off your goal."
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| ling
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c ?
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| robin082006
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E
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The Key to Succeed is Patience.
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| ling
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i agree with robin ....e(based on usmle world)
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| Guptashutosh
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A aspirin
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| Aashi
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One word 'TRICKY'
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"Obstacles are those frightful things you see when you take your EYES off your goal."
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| Aashi
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Answer:
(D) Begin warfarin and adjust the dose based on INR
Explanation:
This patient has paroxysmal atrial fibrillation. His risk of embolism is approximately 5% per year without therapy. Warfarin is the appropriate therapy for him. Aspirin is less effective than warfarin but can be given if the patient has contraindications to warfarin. Elective cardioversion is unnecessary because the patient does not have sustained atrial fibrillation. A transesophageal echocardiogram is also not needed because the patient will start warfarin regardless of the findings.. Electrophysiologic testing (EPS) does not need to be performed because the diagnosis of paroxysmal atrial fibrillation is already made and the therapy is anticoagulation on a long-term basis. The INR should be maintained between 2 and 3.
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"Obstacles are those frightful things you see when you take your EYES off your goal."
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| prathapdoctor
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Please go through the table given in page no 1346, so that we do not commit any misttake regarding prophylaxis in chronic atrial fibrillation.
harrison 16 th edition.
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| ndspider
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The answer is D. We just had a patient with this exact case. You cannot cardioconvert because it is greater than 48 hours. Warfin has greater survival than asprin for the elderly.
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| r_albayunen
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d 
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