A 62-year-old man is brought to the emergency department after complaining of feeling lightheaded and dizzy as well as having chest palpitations. He denies any sense of pain or chest tightness, and does not feel sweaty or short of breath, although he has had myocardial infarctions in the past. However, he does note that he has had a bad œcold and productive, purulent cough for the last week. His pulse is 138/min and examination confirms an irregularly irregular rhythm. Right-sided crackles, egophony, and dullness to percussion are present on chest examination. A chest radiograph shows a corresponding infiltrate, and an electrocardiogram confirms the suspicion of atrial fibrillation. The patient is admitted with a diagnosis of pneumonia and atrial fibrillation and treated appropriately. Over the course of his hospital stay he receives diltiazem, metoprolol, and amiodarone for atrial fibrillation, in addition to empiric antibiotics for community-acquired pneumonia. His outpatient digoxin, used as part of his treatment regimen for congestive heart failure, is continued. Which of the following medications, if given, is most likely to convert his rhythm from atrial fibrillation to sinus rhythm?
A. Amiodarone
B. Digoxin
C. Diltiazem
D. Metoprolol
E. Sotalol
correct but what about this one:
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
the thing i dont understand....he is on 4 of the medications already from the list
the only thing he is not on is sotalol
The American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) Guidelines make the following recommendations regarding pharmacologic conversion of AF:
Conversion of AF less than or equal to 7 days
Agents with proven efficacy include dofetilide, flecainide, ibutilide, propafenone, and to a lesser-degree, amiodarone and quinidine.
Less effective or incompletely studied agents in this scenario include procainamide, digoxin, and sotalol.
Conversion of AF lasting greater than 7 days
Agents with proven efficacy include dofetilide, amiodarone, ibutilide, flecainide, propafenone, and quinidine.
Less effective or incompletely studied agents in this scenario include procainamide, sotalol, and digoxin.
Conversion of AF lasting greater 90 days - Oral propafenone, amiodarone, and dofetilide have been shown to be effective at converting chronic AF to normal sinus rhythm (NSR).
i think warferin
ideally he shouldnt be on beta blockers
amiodarone is not indicated
rate is controlled..so no digoxin
aspirin is a relative CI in asthma
warferin as a thromboprophylaxis
i am not going to give u hard time
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
ookkkkk...right...I always thought..u dont use aspirin in asthma....but i am sure its used...though infrequently
i think the answer is sotalol .
he had a history of MI (CAD)
so DOC is sotalol and secondary choice could be amiodarone and dofetilide.
next choice could be disopyramide, procainamide, Quinidine
Oh i forgot something.
He has CHF .. and is on medication with digoxin.
in this case. DOC would be Amiodarone
no the correct answer is A
The correct answer is A. This patient has underlying heart disease and with this episode of pneumonia went into atrial fibrillation. Amiodarone can chemically convert patients into a sinus rhythm, though it is not highly effective in this role. Its major role is in the maintenance of sinus rhythm once a patient has converted out of atrial fibrillation.
Digoxin (choice B), diltiazem (choice C), and metoprolol (choice D) are all agents used to treat atrial fibrillation. They work by controlling the rapid ventricular response to atrial fibrillation. They are no more successful than placebo for converting atrial fibrillation into a sinus rhythm. However, recently completed studies have shown no difference in mortality among rate-controlled versus rhythm-controlled patients.
Sotalol (choice E) is a class III antiarrhythmic drug. It has not been proven to chemically convert patients out of atrial fibrillation. It is used in a variety of situations to prevent recurrence of supraventricular tachycardias once sinus rhythm is restored.