Tag Archives: AFib

Thursday NF Interesting Case with Sonia and Dr. Robbins : Afib


An eldely man with a hx of hypothyroidism, recent L TKR and a hx of DVT 1 year prior who was called to come to the ED for a heart rate in the 130s found to be in new afib.


Key Learning Points

*Don’t treat subclinical hypothyroidism unless T4 is > 10 or thyroid antibody is +; the reason for treating subclinical hypothyroidism is risk of progressing to an overt hypothyroid state

*IV metop vs. PO Metop

-Per Kaiser Guidelines – oral beta blocker therapy is preferred over IV therapy in the setting of acute MI; oral administration should be initiated within the first 24 hours for MI patients who do not have any of the following (a) heart failure, (b) low output state, (c) increased risk for cardiogenic shock, or (d) other relative contraindications (PR > 240 msec, 2nd or 3rd degree heart block, active asthma or reactive airway disease).   Early aggressive IV beta blockade can pose a net hazard in hemodynamically unstable patients.

*Number to transfuse in setting of ACS?

-The optimal transfusion threshold in the setting of ACS remains unresolved.  In general transfuse when the Hgb is < 8 g/dL and consider transfusion when the Hgb is between 8 and 10 g/dL.  Pilot trial of 110 patients with ACS demonstrated that a liberal transfusion strategy to raise the Hgb >/= 10 was associated with greater survival at 30 days


7/14 Morning Report with Ryan Guiness and Dr. Robbins

A man in his 50s w/ ESRD, HTN, afib on metoprolol/warfarin, and history of TR s/p valve replacement presents with 1 week of palpitations and s/s of heart failure, found to have persistant rate-controlled afib and newly decreased EF of unclear etiology. Stay tuned – sounds like this case is still evolving and we may have an answer soon!
*Take home points: 1) Know the common causes of new/worsening afib 2) Review data on rate versus rhythm control*
Rate versus rhythm control:
*As Moyukh pointed out, data has showed no mortality benefit with rhythm control versus rate control; rate control continues to be recommended as first-line treatment due to ease of medication regimen and decreased drug-related side effects http://www.nejm.org/doi/pdf/10.1056/NEJMoa0708789
*For patients that continue to be symptomatic when rate-controlled, it is reasonable to consider rhythm control. Even if not in RVR, afib can itself cause decreased LV systolic performance and hemodynamic changes due to 1) loss of atrial systole required for optimal ventricular filling 2) activation of neurohormonal vasocontrictors 3) increased MR