Еще одна пилюлька Hескучина

[yananshs]

A 75-year-old woman comes to the office complaining of a 2-day history of palpitations. This morning her palpitations were accompanied by some lightheadedness and nausea. You have been treating her for mitral stenosis and hypertension. The patient has no history of coronary artery disease or arrhythmias, and her exercise stress test from 1 year ago was negative. On physical examination, her pulse is irregular ranging from 110 to 140/min and her blood pressure is slightly lower than usual at 95/70 mm Hg. A mid-diastolic murmur is audible at the cardiac apex, and her jugular venous pressure is estimated to be 8 cm H2O. An electrocardiogram demonstrates atrial fibrillation with rapid ventricular response. You admit the patient to the hospital and she is given a 10 mg bolus of intravenous metoprolol and her heart slows to 90/min. Another electrocardiogram still demonstrates atrial fibrillation and her blood pressure is now 135/85 mm Hg. A heparin infusion is started. She is observed overnight and ruled out for myocardial infarction. After discussing treatment options the patient opts to have elective cardioversion of her atrial fibrillation. Before she can undergo this procedure, she
A. must have a coronary angiogram
B. must have a negative stress test
C. must have a transesophageal echocardiogram
D. needs digoxin loading for rate control
E. requires anticoagulation for 3 weeks

[Anna_Shvedova]

//Е//
Еще нравится трансэзофагеальное ЭХО, но вдруг там чего не увидишь?

[Rodionov]

C. До двух дней римт можно восстанавливать без предварительной подготовки непрямыми антикоагулянтами. При помощи ЧПЭхоКГ убедимся в отсутствии тромбов в ушке ЛП и будем заряжать дефибриллятор.

[yananshs]

Считайте, что два дня прошло.

[Dr.]

Сообщение от yananshs

A 75-year-old woman comes to the office complaining of a 2-day history of palpitations. This morning her palpitations were accompanied by some lightheadedness and nausea. You have been treating her for mitral stenosis and hypertension. The patient has no history of coronary artery disease or arrhythmias, and her exercise stress test from 1 year ago was negative. On physical examination, her pulse is irregular ranging from 110 to 140/min and her blood pressure is slightly lower than usual at 95/70 mm Hg. A mid-diastolic murmur is audible at the cardiac apex, and her jugular venous pressure is estimated to be 8 cm H2O. An electrocardiogram demonstrates atrial fibrillation with rapid ventricular response. You admit the patient to the hospital and she is given a 10 mg bolus of intravenous metoprolol and her heart slows to 90/min. Another electrocardiogram still demonstrates atrial fibrillation and her blood pressure is now 135/85 mm Hg. A heparin infusion is started. She is observed overnight and ruled out for myocardial infarction. After discussing treatment options the patient opts to have elective cardioversion of her atrial fibrillation. Before she can undergo this procedure, she
A. must have a coronary angiogram
B. must have a negative stress test
C. must have a transesophageal echocardiogram
D. needs digoxin loading for rate control
E. requires anticoagulation for 3 weeks

C. must have a transesophageal echocardiogram

[vosk]

"Е". Все-таки гемодинамика стабильна, к чему торопиться? А ТЕЕ можно сделать и непосредственно перед кардиоверсией.
Dmitry Voskovets

[Rodionov]

Наличие ЧПЭхо допускает "стучать" больных без 3-х недельной подготовки.
3 недели непрямых АК - это удлинение госпитализации, МНО-метрия, экономические потери и т.п. Эту больную интереснее "стукнуть" и мухой отправить к кардиохирургам.

[Dr.]

Сообщение от rodionov

Наличие ЧПЭхо допускает "стучать" больных без 3-х недельной подготовки.
.

+ шум .

[vosk]

Сообщение от rodionov

3 недели непрямых АК - это удлинение госпитализации, МНО-метрия, экономические потери и т.п.

а обязательно при стабильной гемодинамике кушать варфарин в условиях госпиталя?
Dmitry Voskovets

[Alexey D]

C будет лучшим выбором.

[papadoctor]

C. TEE should be done to r/o left atrial appendage thrombus prior to DC cardioversion!

[Alevgen]

Я - за С!
Уважаемый papadoctor, а откуда данные про "lss than 24hr", всегда думал, что меньше 48 часов?

[Rodionov]

Сообщение от vosk

а обязательно при стабильной гемодинамике кушать варфарин в условиях госпиталя?

Конечно не обязательно, но в наших "реалиях" хотя бы первая неделя подбора дозы проходит в стационаре.

[Rodionov]

8.2.7. Prevention of Thromboembolism in Patients With
Atrial Fibrillation Undergoing Cardioversion
RECOMMENDATIONS
Class I
1. For patients with AF of 48-h duration or longer, or
when the duration of AF is unknown, anticoagulation
(INR 2.0 to 3.0) is recommended for at least 3
wk prior to and 4 wk after cardioversion, regardless
of the method (electrical or pharmacological) used to
restore sinus rhythm. (Level of Evidence: B)
...
3. For patients with AF of less than 48-h duration
associated with hemodynamic instability (angina
pectoris, MI, shock, or pulmonary edema), cardioversion
should be performed immediately without
delay for prior initiation of anticoagulation. (Level of
Evidence: C)

Class IIa
1. During the first 48 h after onset of AF, the need for
anticoagulation before and after cardioversion may
be based on the patient’s risk of thromboembolism.
(Level of Evidence: C)
2. As an alternative to anticoagulation prior to cardioversion
of AF, it is reasonable to perform TEE in
search of thrombus in the LA or LAA. (Level of
Evidence: B) - наш случай.

[Dr.]

Пока нет новых поступлений, задам веселую задачку. Не из-за сложности, а просто веселую (кажется, USMLE step 3 тоже)

72-летний мужчина, который питается хот-догами и содовой, жалуется на кровоточивость десен и мышечные боли. При осмотре - подногтевые петехии на пальцах рук. Коагулограмма в норме, количество тромбоцитов в норме. Лекарств не принимает. Что подозреваем?