Atrial Fibrillation

Are there any generally accepted guidelines for performing arthrocentesis in patients who are receiving anticoagulants?

A 3-day history of intermittent fainting spells brings a 49-year-old man to youroffice. His only significant medical history includes seasonal allergic rhinitis,for which he takes terfenadine, and mild depression, which is being treatedwith amitriptyline. A week ago, he began taking erythromycin, 500 mg qid,for acute pharyngitis.

Your patient with atrial fibrillation (AF)is hemodynamically stable and youhave successfully established rate control.Your next step is to weigh therisks and benefits of attempting to restoresinus rhythm. In up to one half ofpatients, AF of recent onset convertsspontaneously to normal sinus rhythmwithin 24 hours. Thus, in some cases,the most appropriate approach maybe to control the ventricular response,identify and treat comorbid conditions,initiate anticoagulation, and closelymonitor the patient.

Atrial fibrillation (AF) is the most commonsustained cardiac arrhythmia; itaffects about 2.2 million Americans.The prevalence of AF, which increaseswith age,1 is approximately 5.9% in personsolder than 65 years2 and greaterthan 10% in those older than 75 years.3

A 52-year-old woman was admitted tothe hospital with progressive shortnessof breath of 2 days’ duration. Bronchialasthma had been diagnosed 6 monthsearlier; inhaled corticosteroids, bronchodilators,and leukotriene antagonistswere prescribed. Despite aggressivetreatment, the patient’s dyspneaand wheezing worsened.

Delirium in older adults needs to berecognized early and managed as amedical emergency. Prompt detectionand treatment improve both shortandlong-term outcomes.1,2 Becausedelirium represents one of the nonspecificpresentations of illness in elderlypatients, the disorder can be easilyoverlooked or misdiagnosed. Misdiagnosismay occur in up to 80% of cases,but it is less likely with an interdisciplinaryapproach that includes inputfrom physicians, nurses, and familymembers.3

Abstract: Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common, yet often overlooked, form of symptomatic sleep-disordered breathing. OSAHS is a cause for concern for several reasons, one of which is its association with cardiovascular disease. Risk factors include obesity, hypertension, and upper airway malformations. Diagnostic clues include habitual snoring, witnessed apneas, choking arousals, excessive daytime sleepiness, and large neck circumference. Polysomnography is the definitive diagnostic test; it pro- vides objective documentation of apnea and hypopnea. Since OSAHS may contribute to adverse postsurgical events, consideration of this syndrome should be part of the preoperative assessment of patients. (J Respir Dis. 2006;27(4):144-152)

An 86-year-old woman complains that she has felt "not at all well" for the past day. Her symptoms include diffuse generalized weakness and nausea; she denies chest pain, shortness of breath, abdominal pain, leg swelling, palpitations, and light-headedness. Five years earlier, a pacemaker was implanted as therapy for sick sinus syndrome and atrial fibrillation.

An 82-year-old woman presents with a history of sporadic episodes of light-headedness that began several months earlier and are becoming progressively more frequent. The episodes are unrelated to time of day, degree of activity, or posture. They cause her to feel as if she will lose consciousness, although she has never experienced total syncope.

Are beta-blockers still considered first-line therapy for uncomplicated hypertension?

A 59-year-old woman comes to your office for evaluation of her heart murmur.During the last several months, she has tired more easily and has had less energy.Recreational activities, such as lap swimming, have become difficult becauseshe is easily winded. She denies chest pain, foot swelling, and nocturnal dyspnea.

A 3-year Australian study found that when patients who underwent bypass surgerywere given coenzyme Q10 for a week or more before the operation, their heartmuscle tolerated stress better, recovered more quickly, and had better pumpingability after surgery than did the heart muscle in patients given placebo.1

Numerous factors, includingother drugs, diseases,and diet, affectthe response to warfarin.Some of these factorsdecrease the response and maylead to therapeutic failure; othersenhance the response and may resultin life-threatening bleeding.

Q:What is the best and most efficient method ofevaluating pulmonary function in primary careoffice practice?

Abstract: In the assessment of central airway obstruction and disease, no imaging technique is an adequate substitute for bronchoscopy. The indications for rigid bronchoscopy include multiple malignant and benign disorders, with most interventions performed for treatment of complications of lung cancer. The rigid bronchoscope is a useful tool for managing most types of airway stenoses, and it facilitates other endobronchial therapies, including stent placement, argon plasma coagulation, balloon dilatation, electrocautery probes, and laser therapy. Certain patients with benign lesions or postintubation or post-tracheostomy stenosis may benefit from rigid bronchoscopic techniques instead of surgery. Although use of the rigid bronchoscope requires general anesthesia, it provides a stable airway and often results in fast removal of foreign bodies. (J Respir Dis. 2006;27(3):100-113)

n the first 7 days after a transient ischemic attack (TIA), the risk of a stroke is 10%.1 If half the patients who presented with TIAs were admitted and received an immediate workup within that 7-day window, only 5% of them would have a stroke.1 Thus, many patients would undergo unnecessary tests. Some would have complications, and the costs would be prohibitive. What is needed is a way to identify patients who are at high risk for a stroke in the immediate future--and who require emergent assessment.

Because the causes of syncope are numerous and the diagnostic tests have low yield, this disorder is often difficult to evaluate. Here we describe a practical approach to the workup that can help you rapidly identify serious underlying pathology. We also discuss treatment of the most common causes of syncope.

Although widely regarded as a raredisorder, hereditary hemochromatosisis the most common genetic disease inCaucasians. In certain populations ofnorthern European descent, 1 of every200 persons is homozygous for thecausative mutation.1

A 36-year-old man who had collapsedand sustained a bruised right shoulderwas brought to the emergency departmentwith acute emesis, cephalgia,blurred vision, aphasia, and righthemiparesis. He was confused but ableto follow simple commands.

Abstract: In the assessment of community-acquired pneumonia, an effort should be made to identify the causal pathogen, since this may permit more focused treatment. However, diagnostic testing should not delay appropriate empiric therapy. The selection of empiric therapy can be guided by a patient stratification system that is based on the severity of illness and underlying risk factors for specific pathogens. For example, outpatients who do not have underlying cardiopulmonary disease or other risk factors can be given azithromycin, clarithromycin, or doxycycline. Higher-risk outpatients should be given a ß-lactam antibiotic plus azithromycin, clarithromycin, or doxycycline, or monotherapy with a fluoroquinolone. If the patient fails to respond to therapy, it may be necessary to do bronchoscopy; CT of the chest; or serologic testing for Legionella species, Mycoplasma pneumoniae, viruses, or other pathogens. (J Respir Dis. 2006;27(2):54-67)

35-year-old woman presents to the emergency department with palpitations and chest pain. She is aware of her heart beating fast but not irregularly. She notes associated discomfort in the center of her chest.

22-year-old man is hospitalized because of severe hypertension. In addition, he reports exertional retrosternal pressurelike pain, with a severity of 5/10, that lasts for 2 to 3 minutes.

A 22-year-old woman presents with progressive fatigue and dyspnea on exertion that develops after she walks about 30 feet. She also reports orthopnea, lower extremity swelling, weight gain, dry cough, and paroxysmal nocturnal dyspnea.

How long should anticoagulant therapy be continued in patients with thromboembolic disease?

Abstract: Shortness of breath is a common complaint associated with a number of conditions. Although the results of the history and physical examination, chest radiography, and spirometry frequently identify the diagnosis, dyspnea that remains unexplained after the initial evaluation can be problematic. A stepwise approach that focuses further testing on the most likely diagnoses is most effective in younger patients. Early bronchoprovocation challenge testing is warranted in younger patients because of the high prevalence of asthma in this population. Older patients require more complete evaluation because of their increased risk of multiple cardiopulmonary abnormalities. For patients who have multiple contributing factors or no clear diagnosis, cardiopulmonary exercise testing can help prioritize treatment and focus further evaluation. (J Respir Dis. 2006;27(1):10-24)