Atrial Fibrillation on the Web: Pretest Survey

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1. What is your medical designation?

What is your medical designation? MD/DO

Other

Case Study: 78 year old man with prior myocardial infarction and hypertension presents for evaluation of intermittent sensations of a racing irregular heart rate that occur unpredictably, may last for an hour or two, and then spontaneously abate. Last week the episode lasted an entire day. When symptoms occur, he “just has to sit and rest” because of symptoms of fatigue and anxiety over the “thumping in his chest”. When not experiencing palpitations, he has no physical limitations. Medications include baby aspirin, atenolol 50 mg daily, and hydrochlorothiazide 25 mg daily. On exam, his blood pressure is 138/88, heart rate is regular and 68 beats/minute. Lungs are clear. Cardiac exam manifests a regular rhythm without murmur.
You order a Holter monitor, which returns showing a 2 ½ hour episode of atrial fibrillation averaging 92 beats/minute, during which the patient records feeling “awful” in his event diary.

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2. What is the patient’s CHADS2 score?

What is the patient’s CHADS2 score? 1

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3. What is the patient’s approximate risk of stroke over the course of the next year on his current therapy?

What is the patient’s approximate risk of stroke over the course of the next year on his current therapy? 4%

10%

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4. The patient is reluctant to take warfarin and asks whether there are better alternatives. You advise:

The patient is reluctant to take warfarin and asks whether there are better alternatives. You advise: Increase Aspirin dose to 325 mg daily

Stop baby aspirin and initiate warfarin adjusted to target INR of 2-3

Add clopidogrel 75 mg to his current aspirin dose

Continue his current therapy

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5. What would be your next step in his rhythm management?

What would be your next step in his rhythm management? Increase atenolol dose to 100 mg daily

Add propafenone 150 mg bid

Add dronedarone 400 mg bid

Add amiodarone 400 mg daily

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6. Six months after beginning antiarrhythmic therapy, the patient “feels great” and has had no recurrence of his symptoms. He asks whether he can stop his clot prevention regimen in light of his marked improvement. What would you advise?

Six months after beginning antiarrhythmic therapy, the patient “feels great” and has had no recurrence of his symptoms. He asks whether he can stop his clot prevention regimen in light of his marked improvement. What would you advise? His risk for stroke is now substantially reduced in sinus rhythm and he no longer requires stroke prophylaxis

Check his rhythm on 24 hour Holter. If there is no evidence of recurrent AF he no longer requires stroke prophylaxis; otherwise it should be continued.

Continue his stroke prophylaxis indefinitely

Re-evaluate in 1 year. If symptoms still absent, discontinue stroke prophylaxis.

Atrial Fibrillation on the Web: Pretest

1. Default Section

*1. What is your medical designation?

*2. What is the patient’s CHADS2 score?

*3. What is the patient’s approximate risk of stroke over the course of the next year on his current therapy?

*4. The patient is reluctant to take warfarin and asks whether there are better alternatives. You advise: