Unknown 151

1
Unknown 151
2
Case

• 40 year old man is seen for routine physical, and
  he has no complaints
• PMH N/C
• Family history no cancers or CAD
• Meds None
• Social Hx no smoking/etoh/ivda
• On exam, he is found to have

3
Exam

• VS 37.0, 120/80, 78, 12, 100 RA
• GEN NAD, HEENT negative
• CVS S1S2, irregularly irregular
• PUL CTA bilaterally
• ABD soft, NT/ND, BS
• EXT no c/c/e

4
EKG
5

• Subsequent workup included TFTs, cxr, echo and
  cardiac enzymes which are all within normal limits

6

• What is the appropriate management of this
  patient?
• Lovenox followed by coumadin
• Unfractionated heparin drip then coumadin
• Immediate cardioversion
• Plavix plus Coumadin
• Offer aspirin

7

• What is the appropriate management of this
  patient?
• Lovenox followed by coumadin
• Unfractionated heparin drip then coumadin
• Immediate cardioversion
• Plavix plus Coumadin
• Offer aspirin

8
E) Aspirin only

• 2006 ACC/AHA/ESC guidelines concluded that there
  was no standard definition for lone AF. The
  guidelines applied the term to patients under age
  60 without clinical or echocardiographic evidence
  of heart disease

9
CHADS 2 score

• C  Congestive heart failure 1
•  H  Hypertension (or treated HTN) 1
•  A  Age gt75 years 1
•  D  Diabetes 1
•  S2 Prior Stroke or TIA 2

Gage et al. Validation of Clinical Classification
Schemes for Predicting Stroke. JAMA 2001 285 22
(2864-2870).
10

• Patients are considered to be at low risk with
  a score of 0, at intermediate risk with a score
  of 1 or 2, and at high risk with a score 3.

11

• One exception is that most experts would
  consider patients with a prior ischemic stroke,
  transient ischemic attack, or systemic embolic
  event to be at high risk even if they had no
  other risk factors and therefore a score of 2.

12

• Score of 0 Offer aspirin
• Score of 0-1 ASA or coumadin
• Score of 2 Coumadin
• This assumes no contraindication to
  anticoagulation and no valvular disease.

OBJECTIVE Diagnose and manage atrial
fibrillation in an otherwise asymptomatic patient.