hero
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A 75-year-old man is admitted to the hospital with complaints of shortness of breath, chest pain, and palpitations for the last day. He has a past medical history of diabetes mellitus and hypertension. Three years ago, he underwent coronary artery bypass grafting. His medications at home include metoprolol, nitroglycerin, aspirin, digoxin, and metformin. Sometime in the past he was prescribed coumadin, but then it was stopped for an unknown reason.
On admission, his blood pressure is 90/40 mm Hg, heart rate is 120/minute, and respiratory rate is 24/min. The patient appears pale and slightly diaphoretic. The jugular venous pressure is elevated. The heart rhythm is irregularly irregular. On lung auscultation, there are bibasilar crackles and an S4 gallop. Two sets of cardiac enzymes are negative. The EKG shows atrial fibrillation with a ventricular response of 124/min and T-wave inversion in leads V1 to V4. These T-wave inversions were also was present on an EKG six months ago. The chest x-ray shows pulmonary edema and cardiomegaly. Transthoracic echocardiography reveals moderate left ventricular hypertrophy and an ejection fraction of 45%. The first troponin is negative. What is your next step in management of this patient?
(A) Digoxin, for a total of 1 mg over 24 hours
(B) Direct current cardioversion
(C) Procainamide
(D) Heparin
(E) Transesophageal echocardiogram
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| farnsworth
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D
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| robin082006
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Cardioversion
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| Ivonne
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Synchronous cardioversion
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| RX 135
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prescribed coumadin, but then it was stopped for an unknown reason.
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| hasan82
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bbbbbbbb
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| arlete
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B - the patient is unstable!
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| doc_clotaire
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(B) Direct current cardioversion 
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| inkspot
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B the patient is unstable! darn its easy said than done! the rest of options dont fit it. deal with the emergency first
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| arlete
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It does not matter what arrhythmia ( afib, SVT, VT) the patient has. Low BP = electrical cardioversion!
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| medicus_81
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Hm, that's a really tough call...
I would say the answer is E (stat). The current guidelines prohibit cardioversion as first line treatment in Afib of unknown duration because of the high risk of already formed atrial clots which can shoot up to any part of the body (i.e. can cause a stroke!). so in a normal situation you would put the patient on heparin/coumadin for a couple of months and then cardiovert him. since he is unstable and going into acute HF/pulm edema, I would do a STAT echo,make sure there are no clots and then cardiovert him. In this lovely country if you just go ahead and cardiovert him and he strokes, gues who will pay big bucks to the family...
my opinion guys...
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| inkspot
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clots where?
the question clearly mentions the pt is having Afib. ( warfarin should be given along side while preparing for cardioversion)
I think transoesophageal echo will WASTE lots of time in patient who is dying. and more over you will need patients cooperation to swallow the tube- would that be possible with this patient who is loosing consious?
cardiovesion all the way -- what do you think?
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| farnsworth
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Medicus81:
if the patient is unstable, you can cardiovert him without doing an echo (according to AHA guidelines, 2005 or so). So (B) is the most likely solution.
If the patient has Afib for <48h and is anticoagulated, you can cardiovert him to, without an echo. When Afib persisted for more than 48h, you should do either a TEE guided cardioversion or 3 weeks of oral anticoagulation followed by cardioversion.
This case is tricky: the patient arrives at the emerg with a MAP<60 and tachycardic AFib. First things first: oxygen, monitoring (ECG, SpO2, BP), IV line. Then you do a 12-lead ECG (see above). If you decide that the patient is unstable (bibasilar crackles, elevated JVP, AFib...), than DO a cardioversion without echo and initiate anticoagulation therapy (solution B).
So in this case, someone decided to check the ECG done months ago, tells you about the T-wave inversions (more ore less useless information: the patient is on digoxin! Furthermore the patient underwent CABG), but does not tell you about the rhythm months ago, which could explain why the patient was on coumadin. More time passed doing the CXR and waiting for the interpretation (ok, lets say, you do not wait for the interpretation, but you look at the CXR yourself on the computer screen, almost all portable CXR are digital, so from ordering a CXR to getting the picture may take less than 5min). Then you decide you need an TTE for estimation of the EF. Gold standard for exclusion of thrombi (or spontaneous left atrial echogenic structures) would be TEE, as the left atrium lies adjacent to the esophagus (you can visualize the left atrium from ME 2chamber, ME LAX...). Meanwhile the TropI value comes in. All in all approx 20min passed, before you decide, that the patient is unstable and needs immediate cardioversion...
I don't think, that patient is a suitable candidate for oral anticoagulation and waiting for another 3 weeks for cardioversion, but after doing the 12lead ECG and diagnosing him with AFIB, you could at least give him heparin. This action does not 'eat' your time, because you can simply order it and you can either proceed to immediate cardioversion or do a TEE and cardiovert afterwards.
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| nyimalay
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Since, the question indicates that he has been off from coumadin that was indicated for his risk of having thrombus, start heparin and then cardiovert is the most appropriate action.
So my answer is D.
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| medicus_81
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Pals,
Like I said it is a tough call! I alredy said that heparinize him and put him on coumadin for a later cardioversion is not an option! I am also aware of the 48h cut-off but this question does not deliver any information about how long the afib has existed... And I totally dismissed the fact the it said TEE - I agree with you the patient would not tolerate it (stupid me), I thought it just said just echo...
I just digged this one out: AHA guidelines 2006:
Class I
When a rapid ventricular response does not respond promptly to pharmacological measures for patients with AF with ongoing myocardial ischemia, symptomatic hypotension, angina, or HF, immediate R-wave synchronized direct-current cardioversion is recommended. (Level of Evidence: C) Immediate direct-current cardioversion is recommended for patients with AF involving preexcitation when very rapid tachycardia or hemodynamic instability occurs. (Level of Evidence: B) Cardioversion is recommended in patients without hemodynamic instability when symptoms of AF are unacceptable to the patient. In case of early relapse of AF after cardioversion, repeated direct-current cardioversion attempts may be made following administration of antiarrhythmic medication. (Level of Evidence: C)
Level of Evidence
The weight of evidence was ranked from highest (A) to lowest (C), as follows:
- Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses.
- Level of Evidence B: Data derived from a single randomized trial, or nonrandomized studies.
- Level of Evidence C: Only consensus opinion of experts, case studies, or standard-of-care.
Hope this helps.
Edited by medicus_81 on 02/04/08 - 08:49 AM
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| farnsworth
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Hey, medicine is never easy and it's almost never just black and white.
Algorithm from Lip et al, Lancet 2007
Regarding TEE: the patient most likely requires some kind of sedation, most people prefer midazolam. It is not a good idea, to use midazolam in an unstable patient, as the patient is extremely prone to pulmonary edema (bibasilar crackles) and suppressing the respiratory drive w/ midazolam would required intubation, as you can't do an echo with the patient on non-invasive ventilation (NIV). At least not w/ the NIV masks I know: they have a port, but this is just big enough to do a flexible bronchoscopy...
On the other hand, a cardioversion without sedative/analgetic is considered unethical. In this particular case (hemodynamically compromised patient) etomidate may be the drug of choice for cardioversion.
In stable patients for elective cardioversion you could use alfentanil in combination with propofol (extremely short recovery time!)
Attached Files:
Algorithm Afib.jpg (130 KB, 32 downloads)
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| SmokyWaters
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For AF duration less than 48 hours associated with hemodynamic instability (as manifested by angina, myocardial infarction, shock, or pulmonary edema), immediate cardioversion should be performed with delay for prior initiation of anticoagulation.
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| SmokyWaters
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there is clear instability
so the answer should be direct cardioversion
Attached Files:
afib.JPG (113 KB, 17 downloads)
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| elixir
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with all that's been said,i think the most likely answer's B
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| simi
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hero...can u post the ans given for this plz.
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| dr ruman
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cardioversion without wait for TEE and COUMARIN as pt instable{reference kaplan)
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| WaqasQureshi
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b
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