AFib - pacemaker

[ArchivalUser]

A 61-year-old man is evaluated in the emergency department for mild left-sided weakness and left visual field loss that began about 6 hours ago. He has a history of diet-controlled hypertension. His current blood pressure is 160/75 mm Hg, and heart rate is 110/min and irregular.

Physical examination reveals an irregularly irregular cardiac rhythm but is otherwise normal. Neurologic examination reveals a partial left homonymous hemianopsia, a left central facial palsy, mild left upper-extremity weakness, and mild left sensory loss. Complete blood count and serum electrolytes and glucose are normal. Electrocardiography reveals atrial fibrillation. CT scan of the brain shows early hypodensity of the right basal ganglia and insula.

Which of the following is the most appropriate therapy?

A Warfarin
B Enoxaparin
C Clopidogrel
D Adenosine

[ArchivalUser]

C?

[ArchivalUser]

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[ArchivalUser]

he is having an ishemic infarct and its been 6 hours since the manifestation, so go for LMWH SC

[ArchivalUser]

yeah, u are right, when we have conditions causing thromboembolism we give heparin so it shud be b

[ArchivalUser]

B.

[ArchivalUser]

whats the ans pace,,,,,,,,,clopidogrel is an anti-plat not of much help here as here the cause is thrombus from AF leading to ischemic infarct as suggested by the CT hypodense lesions which are dark due to no blood
where as hemorrhagic infarcts are white hyperdense due to blood extravasation

[ArchivalUser]

i mean recurrent thromboembolism.
otherwise heparin is dangerous in case of ischemic infarct, am i right? or do i have to go back to my book again?

[ArchivalUser]

A)
Key Points

* Secondary prevention of cardioembolic stroke consists of warfarin with a target INR of 2.0 to 3.0.
* Heparin has no established role in the acute treatment of stroke.

The patient has an acute infarction involving the right middle cerebral artery territory. Although he has no history of atrial fibrillation, it was likely present but previously undiagnosed. He is not eligible for acute thrombolytic therapy because he could not be treated within 3 hours of symptom onset; however, the patient would benefit from early intervention of secondary prevention measures. He is at high risk for future cardioembolic strokes and would achieve substantial risk reduction with warfarin to maintain an INR between 2.0 and 3.0.

Early use of either unfractionated or low-molecular-weight heparin is dangerous in acute ischemic stroke, and therefore enoxaparin is inappropriate. Clopidogrel has not been shown to be effective in either acute stroke or in the prophylaxis of stroke due to atrial fibrillation, although it is effective in secondary prevention of non-cardioembolic stroke. Adenosine does not effectively treat atrial fibrillation nor prevent stroke.

[ArchivalUser]

thanks pacemaker. thts a great explanation.