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  #1  
Old 09-04-2012
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Default do we cardiovert chronic afib ?

When to cardiovert chronic afib ? After 3-6 weeks trial of warfarin or not done ? i knw we do cardiovert but strangely MTB mentions its no longer done..just to double check if its correct...
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Old 09-04-2012
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From my notes out of kaplan + MTB + DIT and for the sake of the exam...according to protocol...

once determining whether hemodynamically stable?
no! --> synchoronized cardioversion

yes -->...then rate control --> give them Digoxin along with BB or CCB (verapamil or diltiazem) + heparin & warfarin

now we need more information...is this duration of Afib> 48 hours?

no! --> then synchronized cardioversion

yes OR UNKNOWN (amount of time)--> then you would either do a TEE or anticoagulate for 3 weeks...

but in real life who the hell wants to sit there for 3 weeks and wait?

The reason you are doing a TEE is because you want to know RIGHT NOW if there is A CLOT! so this will allow you to determine this so you can anticoagulate RIGHT NOW!

so from the consensus from my readings and knowledge...yes you do cardioversion that is ultimately the goal if you do a TEE now or if you anticoagulate for 3 weeks and then cardiovert...

now for MTB dilemma...I'm using MTB 3 and it says the next best step for stable patient:
  • ventricular hear rate slowed if it is >100
  • rate control meds = Digoxin, BB, CCB (acute setting given IV)
  • once your rate is under control --> anticoagulate via heparin & warfarin (INR of 2-3)
then it says like you mentioned in the MTB 3..."routine cardioversion of atrial fibrillation is not indicated...the long term use of rate control medications, such as metoprolol, diltiazem, or digoxin, combined with anticoagulation is equal or better than cardioversion with electricity or medications"


this part mentioned in red, need to keep in mind that it's for step 3 CCS, and if you and if you are relying on kaplan internal medicine notes...then for the sake of the step 2...stick with cardiovert....they want to see if you know the protocol....for step 3 ccs when you are picking treatment then obviously you would go with long term use of rate control medications and anticoagulation which is equal or better to cardioversion....everything is the same except when it comes down to ccs tx then rate control and anticoagulation is superior to cardioversion...



this protocol business was a pain in my butt and I went through 3 sources to understand...and also if you want a visual diagram...there is one in step up to medicine step 3...having a diagram helps me alot....



I hope this helps you...sorry for the long post...just wanted to be thorough!
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Old 09-04-2012
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Chronic AF: Not routinely cardioverted since they revert back to AF in 90% of patients.

Protocol:

With risk factors for stroke: Rate control and Warfarin

With risk factors for stroke & a atrial thrombus: Rate control & Heparin+Warfarin

Without risk factors for stroke (aka Lone AF): Rate control and Aspirin

Rhythm control is useful in hemodynamically unstable patients but in stable patients rate control is done along with anticoagulation since the aim is to prevent stroke.

According to UW cardioversion is only done in hemodynamically unstable patients (electrical) & in stable patients (electrical or pharmacological) with less than 48 hr of AF meaning that cardioversion is only useful in an acute setting.

Last edited by Novobiocin; 09-04-2012 at 06:48 PM.
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Old 09-04-2012
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novobiocin...you are right that's what it says in step up to medicine...

I wanted to point out one more thing....what I wrote up there was for an acute setting...depending on the information provided

Acute Setting + Unknown duration OR 2 days (>48 hours):


according to conrad fischer...he says at an acute setting you can do a TEE or anticoagulate them first....but you want to know right now....
if there is a clot or not that's why would do a TEE and then the following:

Acute setting + TEE + thrombi ==> rate control + anticoagulate & wait 3-4 weeks --> cardioversion

Acute setting + TEE + no thrombi--> rate control and cardiovert

Long Term = chronic AFib = recurrent cases
from MTB 3...long term you will just do rate control + anticoagulation because it's superior to cardioversion...meaning you can still cardiovert them...
If the patient has recurrent cases = chronic AFib then a AV nodal ablation would be considered...

the only thing is I don't know how far in depth they will go with this...since you have the option of cardioverting < rate control + anticoagulation, and depending on chronicity AV nodal ablation...

**I assume this would be at the physician's discretion**

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Old 09-06-2012
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Quote:
Originally Posted by Novobiocin View Post
Chronic AF: Not routinely cardioverted since they revert back to AF in 90% of patients.

Protocol:

With risk factors for stroke: Rate control and Warfarin

With risk factors for stroke & a atrial thrombus: Rate control & Heparin+Warfarin

Without risk factors for stroke (aka Lone AF): Rate control and Aspirin

Rhythm control is useful in hemodynamically unstable patients but in stable patients rate control is done along with anticoagulation since the aim is to prevent stroke.

According to UW cardioversion is only done in hemodynamically unstable patients (electrical) & in stable patients (electrical or pharmacological) with less than 48 hr of AF meaning that cardioversion is only useful in an acute setting.

let me know if m rt

the choice of anticoagulant depends
C - CAD 1
H - htn 1
A - age mre than 75 1
D - DM 1
S - stroke 2

score = 0 low risk treat wid aspirin alone
score mre thn 2 increase risk of emboli + treat wid anticoagulants
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Old 09-06-2012
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Quote:
Originally Posted by drshaziamirza View Post
let me know if m rt

the choice of anticoagulant depends
C - CAD 1
H - htn 1
A - age mre than 75 1
D - DM 1
S - stroke 2

score = 0 low risk treat wid aspirin alone
score mre thn 2 increase risk of emboli + treat wid anticoagulants
You are absolutely right about CHADS2 score

Quote:
Score.......... .............Risk...........................Antico agulation Therapy......... Considerations
.............0 ............. Low ........................None or Aspirin .....................Aspirin daily
.............1........ ......Moderate....................Aspirin or Warfarin.............Aspirin daily or raise INR to 2.0-3.0,
......2 or greater
..... Moderate or High........... Warfarin .........Raise INR to 2.0-3.0, unless contraindicated

Last edited by Novobiocin; 09-06-2012 at 09:05 AM.
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