ucla family medicine department img program carlos yoo
TRANSCRIPT
UCLA Family Medicine Department IMG Program
Carlos Yoo
A 66 year-old man comes to the emergency department complaining of a several-day history of an intermittent sensation of fluttering in the chest. He feels weak when the episodes occur but denies chest pain or shortness of breath. He has had hypertension for 20 years, controlled well with enalapril, and he takes albuterol for asthma. He denies any alcohol use.
UCLA Family Medicine Department IMG Program Carlos Yoo
VS: Temperature 36.8C (98.3F), Blood pressure 140/80, pulse 140/min, respirations 12/min
PE: supple neck, no jugular vein distension or thyromegaly.
CV: irregularly irregular rhythm with no rubs or gallops.
Chest: clear sounds Abd: Benign Extremities: no edema
UCLA Family Medicine Department IMG Program Carlos Yoo
Atrial Fibrillation Multifocal atrial tachycardia Supraventricular tachycardia Pulmonary Embolism Thyrotoxicosis
UCLA Family Medicine Department IMG Program Carlos Yoo
EKG Thyroid Function tests Cardiac enzymes Echocardiogram ABGA
UCLA Family Medicine Department IMG Program Carlos Yoo
Within Normal limits
Normal
Within Normal limits
Normal Ejection fraction, left atrial enlargement
Elderly patientPalpitation
Fatigue/weaknessLong term hypertension
TachycardiaIrregularly irregular rhythm
EKG: atrial fibrillation waves, inconsistent R-R intervals, absence P waves.
UCLA Family Medicine Department IMG Program Carlos Yoo
ATRIAL FIBRILLATION
GOALS› Hemodynamic stabilization› Ventricular rate control› Prevention of embolic complication
UCLA Family Medicine Department IMG Program Carlos Yoo
Patient with diagnosis of atrial fibrillation
Hemodynamically stable
Control ventricular rate:Diltiazem
Cardioversion
Yes No
Spontaneous conversion to sinus rhythm
Assess cause of atrial fibrillation
Yes No
Contraindication to cardioversion?
Cont’
•Beta Blockers•Calcium Channel blockers•Digoxin•Amiodarone
Unstable…•Hypotension•Confusion•Angina•….
Long standing HTNIschemic heart dz
CHFHyperthyroidism
PELung caAlcohol
HypothermiaElectrolytes imbalance
Etc. .
UCLA Family Medicine Department IMG Program Carlos Yoo
Consider long-term anticoagulation
Cardiversion
Yes No
>48hs<48hs
Start Heparin IV
•Immediate medical or electrical cardioversion
•Later elective cardioversion after 3weeks of warfarin• Early TEE-guided cardioversionAtrial fibrillation
persist?
Assess cause of atrial fibrillation
Yes
No
Cont’
Long standing HTNIschemic heart dz
CHFHyperthyroidism
PELung caAlcohol
HypothermiaElectrolytes imbalance
Etc. .
Warfarin Aspirin
http://www.chestjournal.org/content/135/3/849.full.html
http://www.aafp.org/afp/20020715/249.html
http://www.aafp.org/afp/20020715/261.html
http://www.americanheart.org/downloadable/heart/222_ja20017993p_1.pdf
UCLA Family Medicine Department IMG Program Carlos Yoo