cirus
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A 61-year-old man is evaluated in the emergency department for mild left-sided weakness and left visual field loss that began about 6 hours ago. He has a history of diet-controlled hypertension. His current blood pressure is 160/75 mm Hg, and heart rate is 110/min and irregular.
Physical examination reveals an irregularly irregular cardiac rhythm but is otherwise normal. Neurologic examination reveals a partial left homonymous hemianopsia, a left central facial palsy, mild left upper-extremity weakness, and mild left sensory loss. Complete blood count and serum electrolytes and glucose are normal. Electrocardiography reveals atrial fibrillation. CT scan of the brain shows early hypodensity of the right basal ganglia and insula.
Which of the following is the most appropriate therapy?
A. Warfarin
B. Enoxaparin
C. Clopidogrel
D. Adenosine
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| young_doc
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B
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| prathapdoctor
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yeah, its B.
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| sailing boat
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yep agreed lmw heparin , enoxaparin
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| cirus
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Ans is A??
well I answered like this but we all got it wrong, i'm still not convinced with the explanation posted & I think I'll still answer it LMWH on the exam.
Here is the explanation
The patient has an acute infarction involving the right middle cerebral artery territory. Although he has no history of atrial fibrillation, it was likely present but previously undiagnosed. He is not eligible for acute thrombolytic therapy because he could not be treated within 3 hours of symptom onset; however, the patient would benefit from early intervention of secondary prevention measures. He is at high risk for future cardioembolic strokes and would achieve substantial risk reduction with warfarin to maintain an INR between 2.0 and 3.0.
Early use of either unfractionated or low-molecular-weight heparin is dangerous in acute ischemic stroke, and therefore enoxaparin is inappropriate. Clopidogrel has not been shown to be effective in either acute stroke or in the prophylaxis of stroke due to atrial fibrillation, although it is effective in secondary prevention of non-cardioembolic stroke. Adenosine does not effectively treat atrial fibrillation nor prevent stroke.
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| young_doc
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Now that i look into it, you're absolutely right!
"Heparin/Warfarin have no been proven to have efficacy in acute ischemic strokes".
And since it's too late for thrombolytic therapy, the best bet here is to just prevent future strokes, by giving warfarin for his A. Fib..
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| doc_clotaire
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good question
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