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Old 10-19-2011
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Default Cardiology

A 48-year-old man is found to have an irregularly irregular pulse during his annual physical examination. The patient has no current complaints and is unaware of his irregular pulse. He does not have chest pain or any noticeable palpitations. An electrocardiogram is ordered and shows atrial fibrillation with a ventricular rate of approximately 86/min. Aside from asthma requiring occasional use of an albuterol inhaler, he has no significant past medical history. The rest of his physical examination is unremarkable. His other vital signs are within normal limits. At this time, which of the following is an appropriate outpatient pharmacotherapy to consider?
A. Amiodarone
B. Aspirin
C. Digoxin
D. Metoprolol
E. Warfarin
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Old 10-19-2011
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E. Warfarin?
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Old 10-19-2011
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A. Amiodarone
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Old 10-20-2011
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E. Warfarin
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Old 10-20-2011
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its aspirin
depending upon CHADS scoring system his score is 0.
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Old 10-20-2011
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may b Warfarin??
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Old 10-20-2011
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Correct Answer Answer

The correct answer is B. Atrial fibrillation imparts a risk for stroke six times that of sinus rhythm and requires rate control with anticoagulation or rhythm conversion. This patient is relatively young and has no associated stroke risk factors, such as hypertension, diabetes, or heart failure. Young patients (less than age 65 years) with lone atrial fibrillation (no associated risk factors) do not require anticoagulation with warfarin. Lone atrial fibrillation imparts a risk for stroke of less than 1% annually until at least one’s mid 60s. Aspirin provides adequate anticoagulation in patients with lone atrial fibrillation. Recent studies have shown that patients with lone atrial fibrillation may either be treated with aspirin or no thrombolytic therapy.

Amiodarone (choice A) is a class III antiarrhythmic agent that may be used for rate and rhythm control. It is a commonly used antiarrhythmic, as it has a relatively low incidence of proarrhythmia compared with other agents. It is used often in maintenance of a sinus rhythm, as it has the highest efficacy of rhythm control among the antiarrhythmics. Its use should be avoided in young patients, however, as long-term use imparts significant dose-dependent toxicity, including pulmonary fibrosis, thyroid disease, and liver dysfunction. Further, it should be started on an inpatient basis, as it carries a 1 to 2% chance of proarrhythmia, mainly from long QT syndrome.

If this patient had a rapid pulse or suffered from congestive heart failure, digoxin (choice C) would be an appropriate choice. It increases contractility and inhibits atrioventricular nodal conduction. Metoprolol (choice D) also can be used for rate control. This patient does not have a rapid ventricular rate.

Warfarin (choice E) should be used for anticoagulation in all atrial fibrillation patients other than those with lone atrial fibrillation or contraindications to warfarin (intracranial hemorrhage, unstable gait, falls, syncope, poor compliance). Given the significant risk for bleeding, it should not be used in patients with a low risk for stroke, such as those with lone atrial fibrillation.
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