Site MapHelpFeedbackClinical Case 2
Clinical Case 2
(See related pages)

Objectives:

  • Weigh the advantages and disadvantages of maintaining a patient with atrial fibrillation in normal sinus rhythm
  • Define “lone atrial fibrillation”
  • Manage anticoagulation and atrial fibrillation vis-à-vis surgery
  • Manage the over-anticoagulated patient



1

A 65-year-old male with a history of chronic atrial fibrillation is referred to you for "medical clearance" for surgery. He has a history of hypertension and hypercholesterolemia. He has normal cardiac function otherwise with a normal ejection fraction and no valvular disease. Which of the following options would be appropriate for this patient?
A)Anticoagulate the patient with warfarin and allow him to stay in atrial fibrillation.
B)Place the patient on aspirin and allow him to stay in atrial fibrillation.
C)Give digoxin to cardiovert the patient.
D)Strongly suggest cardioversion to this patient since sustained normal sinus rhythm yields the best long-term outcomes.
E)Add furosemide to prevent the development of CHF and edema.
2

In discussing this patient’s care, the surgeon asks if this patient really needs anticoagulation because of his “lone atrial fibrillation.” You believe that her assumption is incorrect.

The criteria for “lone atrial fibrillation,” which allows one to use aspirin rather than warfarin as an anti-embolic drug, include all of the following EXCEPT:

A)Absence of hypertension.
B)Age < 60.
C)Absence of coagulopathy.
D)No prior cardiac history.
E)No history of valvular heart disease.
3

The reason this 65-year-old initially came to see you is because of right upper quadrant pain that you have diagnosed as cholelithiasis. He needs surgery to remove his gallbladder.

Which of the following approaches is the best for controlling his anticoagulation given that he needs surgery?

A)Stop the warfarin several days before surgery to allow his INR to normalize. Restart the warfarin after surgery.
B)Hospitalize the patient a couple of days ahead of time and start heparin. Then stop his warfarin. Restart the warfarin after surgery.
C)Use low-molecular-weight heparin at home and stop the warfarin once this is started. Restart the warfarin after surgery.
D)Stop the warfarin several days before surgery to allow his INR to normalize. Start heparin after surgery and simultaneously restart warfarin.
4

The patient has his surgery and returns to your clinic for a postoperative checkup 1 month after his surgery. You check his INR and it is noted to be 5.2. There is no active bleeding. The most appropriate action at this point is to:
A)Hospitalize the patient for observation since he is at a high risk of bleeding.
B)Give the patient 5 mg of vitamin K orally.
C)Give the patient 2 units of fresh frozen plasma to reverse his anticoagulation.
D)Reduce the patient’s warfarin dose.
E)A, B, and C.
5

The patient misunderstands your instructions and takes an extra dose of warfarin that evening and for the next 2 days. He returns to your clinic and his INR is now 10. What is the most effective form of therapy indicated for this patient at this point in time?
A)5 mg vitamin K IV.
B)Fresh frozen plasma.
C)1 mg vitamin K PO.
D)5 mg vitamin K PO.
E)10 mg vitamin K IV.





We welcome your feedback. Please send comments and questions to: medical_education@mcgraw-hill.com.
To learn more about the book this website supports, please visit its Information Center.
(c)2005 McGraw-Hill Professional
Any use is subject to the Terms of Use and Privacy Policy.
McGraw-Hill Professional is one of the many fine businesses of The McGraw-Hill Companies.


Harrisons Internal MedicineOnline Learning Center

Home > 08. Cardiovascular > Clinical Case 2