robin082006
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Lone AF
treatment is controversable.
I go with
B-------> Place the patient on aspirin and allow him to stay in atrial fibrillation.
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| huyniid
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C. Control the rhythm (best by betablocker). Indication of coagulation when there is risk of tromboemboli. This pt is preop evaluation therefore AF must be controlled first
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| robin082006
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Why do you sue rate control when his rate is normal?
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| huyniid
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The vignette didnot state about the rate of AF. Therefore, assuming that he doesnot have SSS to make the AF with slow ventricular rate
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| robin082006
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This is LONE AF, or asymptomatic AF,
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| huyniid
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Robin@ just for discussion:
uptodate 14.3
DEFINITION — Lone atrial fibrillation (AF) was initially defined in the era before modern echocardiography to identify a cohort of young patients with AF who had no clinical evidence of cardiovascular disease and were at low risk for thromboembolism [1-3]. Patients could have paroxysmal, persistent, or chronic AF [4]. With the availability of echocardiography, the definition includes no echocardiographic evidence of cardiac or pulmonary disease [4,5].
However, certain questions remain unanswered, including patient age, other comorbid conditions, and the importance of mild echocardiographic abnormalities. Lone AF has generally been applied to patients under 60 years of age [4,5]. However, some studies have included those up to age 65 or even older who, as described below, appear to be at increased thromboembolic risk compared to younger patients [6,7]. In some risk models of patients with AF, the presence of diabetes is considered a risk factor for thromboembolism (show table 1A-1C and show table 2) [5,8-11]. By conventional definitions, such patients could still have lone AF. There are no data concerning whether or how the presence of mild echocardiographic abnormalities (eg, mild mitral regurgitation, left atrial enlargement, or increased left ventricular mass) alter the natural history of lone AF.
Based upon these unresolved issues, the 2006 ACC/AHA/ESC guidelines concluded that there was no standard definition for lone AF [5]. The guidelines applied the term to patients under age 60 without clinical or echocardiographic evidence of heart disease. However, a strict definition may no longer be important because a larger number of patients in addition to those with lone AF are at low risk for thromboembolism.
The therapeutic options of rhythm control (cardioversion followed, in patients with recurrent AF, by antiarrhythmic drugs or nonpharmacologic approaches to maintain sinus rhythm) and rate control (usually a beta blocker or calcium channel blocker) are similar in patients with lone AF as in those with underlying cardiac disease. Randomized controlled trials have shown that the embolic risk is similar with both strategies, although patients with lone or low risk AF were largely excluded. (See "Rhythm control versus rate control in atrial fibrillation").
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| Luckyall
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A 
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| zaidsuror
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i BELIEVE THE ANSWER IS D SINCE THOSE WITH CHRONOC ATRIAL FIBRILATION HAVE A 5 TOME GREATER RISK OF STROKE THAN THE NORMAL POPULATION
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| arlete
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This is not lone AF, since the patient has hypertension.
We always try to cardiovert the patient, after fully coagulated, but the longer he's being on AF, the smaller the chance he'll sustain sinus rhythm.
Digoxin does not cardiovert, only reduces the ventricular rate. Because the patient has hypertension, betablockers or calcium channel blockers would be better indicated.
My answer is:
D) Strongly suggest cardioversion to this patient since sustained normal sinus rhythm yields the best long-term outcomes.
Letter E sounds very odd for me.
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| nadiabarati
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D
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| Aashi
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D) Strongly suggest cardioversion to this patient since sustained normal sinus rhythm yields the best long-term outcomes.
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| filatino
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I agree with "D" too.
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| usmile2
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A
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| 92306
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The correct answer is A.
Outcomes of patients in atrial fibrillation who are rate-controlled and anticoagulated are actually better than are the outcomes in those in whom normal sinus rhythm is maintained using antiarrhythmics.
Answer B is incorrect because aspirin should only be used in patients with lone atrial fibrillation and in patients who are at high risk for falls, etc.
Answer C is incorrect because digoxin will not convert atrial fibrillation. It may help in those with CHF by improving cardiac function (and therefore predispose to spontaneous conversion), but it will not convert atrial fibrillation.
Answer D is incorrect because trying to maintain normal sinus rhythm actually increases mortality, hospitalizations, etc.
Answer E is incorrect since the patient is rate-controlled, has normal cardiac function, and does not need furosemide.
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| robin082006
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recheked
Answer is A...........A) Anticoagulate the patient with warfarin and allow him to stay in atrial fibrillation.
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| usmile2
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thank you 92306 for confirming. What's the source of the question if you don't mind.
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| arlete
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Very interesting... If you have the reference, please, give us (it goes against everything I believed). Thanks for sharing.
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| neo335
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i was just wondering.. wont anticoagulating the pt hinder in the surgery thatis to follow? please can anyone explain this to me.. thank u
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| arlete
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Good point. Anticoagulation has to be suspended for the surgery, as well as Aspirin (if that was the case).
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