● PMI laterally displaced: 5th intercostal space, anterior axillary line (AAL), representing left ventricular hypertrophy. ● Bilateral pitting ankle edema (+4), sacral/back edema (+ 2). ● Bibasilar crackles and productive cough. ● Positive jugular vein distention. ● Decreased capillary refill; extremities cool to touch. ● Azotemia (elevated BUN/creatinine) was present on her CMP. TSH, Free T 4, and troponin were all normal. ● CXR reveals cardiomegaly with pulmonary vascular changes and bilateral pleural effusions. ● 12-Lead EKG reveals atrial fibrillation, rapid ventricular rate (RVR), with frequent premature ventricular contractions (PVCs). Also noted are biphasic P waves, left ventricular hypertrophy (indicated by increased amplitude of the QRS complex), and the presence of a right bundle branch block. She has no ST elevation. Serial EKGs are ordered daily with admission orders. ● 2D echocardiogram reveals left atrial enlargement and EF of 65%, no presence of diastolic dysfunction or wall motion abnormality. Providers should consider the following: Self-Assessment Quiz Question #1 What could be the etiology of this patient’s acute CHF? a. Diastolic dysfunction. b. Loss of atrial kick. c. Pulmonary vascular congestion. d. High blood pressure.
Self-Assessment Quiz Question #5 Given the patient’s CHA 2 DS 2 ‑VASc score, would she be a
candidate for anticoagulation? a. No, very low risk for stroke. b. Yes, moderate risk for stroke. c. Yes, high risk for stroke. d. No, high risk for bleeding.
Self-Assessment Quiz Question #6 Which agent would be used to provide immediate anticoagulation? a. Warfarin. b. Unfractionated heparin IV. c. Clopidogrel. d. Full dose aspirin. Self-Assessment Quiz Question #7 Left ventricular hypertrophy (LVH) is associated with which component of cardiac output? a. Preload. b. Afterload. c. Contractility. d. Heart rate. Self-Assessment Quiz Question #8 Which diagnostic test would be most helpful if DC cardioversion is needed? a. Stress test. b. 2D echocardiogram. Given that the patient has structural heart disease (HTN and heart failure), which agent would be best used for conversion to NSR? a. Flecainide. b. Amiodarone. c. Diltiazem. d. Digoxin. Self-Assessment Quiz Question #10 Which of the following are considered a direct thrombin inhibitor? c. TEE. d. EPS. Self-Assessment Quiz Question #9
Self-Assessment Quiz Question #2 What is the classification of her AF? a. Paroxysmal. b. Persistent. c. Long-standing persistent. d. Permanent.
Self-Assessment Quiz Question #3 What aspects of her 12-lead EKG placed her at risk for
developing atrial fibrillation? a. Right bundle branch block. b. Biphasic P waves. c. Left ventricular hypertrophy. d. All of the above.
Self-Assessment Quiz Question #4 What is the patient’s CHA 2 DS 2 ‑VASc score?
a. 1. b. 2. c. 3. d. 4.
e. Rivaroxaban. f. Dabigatran. g. Apixaban. h. Edoxaban.
References • Alalwan, A., Voils, S. A., & Hartzema, A. G. (2017). Trends in utilization of warfarin and direct oral anticoagulants in older adult patients with atrial fibrillation. American Journal of Health System Pharmacology, 74 (16), 1237- 1244. https://doi.org/10.2146/ajhp160756. • Banasik, J. L. & Copstead, L. E. (2018). Pathophysiology (6 th ed.). Elsevier. • Chen, A., Stecker, E., & Warden, B. A. (2020). Direct oral anticoagulant use: A practical guide to common clinical challenges. American Heart Association, 9:e 017559. • https://doi.org/10.1161/JAHA.120.0175591 • Chung, M. K., Refaat, M., Shen, W. K., Kutyifa, V., Cha, Y. M., Baise, L. D., Baranchuk, A., Lampert, R., Natale, A., Fisher, J., & Lakkireddy, D. R. (2020). Atrial fibrillation: JACC council perspectives. Journal of the American College of Cardiology, 75 (14), 1689-1713. https://doi.org/10.1016/j.jacc.2020.02.025 • David, M. N. & Shetty, M. (2021). Digoxin . https://www.ncbi.nlm.nih.gov/books/NBK556025/ • Engelke, Z. (2018). Patient education: Preparing the patient for cardioversion . Cinahl Information Systems. EBSCO Publishing . • Florek J. B. & Girzadas, D. (2021). Amiodarone . https://www.ncbi.nlm.nih.gov/books/NBK482154/ • Frost, J. L., Campos-Outcalt, D., Hoelting, D., LeFevre, M., Lin, K. W., Vaughan, W., & Bird, M. D. (2017). Pharmacologic management of newly detected atrial fibrillation: Updated clinical practice guideline. American Academy of Family Physicians. https://www.aafp.org/dam/AAFP/documents/patient_care/clinical_ recommendations/a-fib-guideline.pdf . • Giardina, E. G. & Zimetbaum, P. J. (2018). Amiodarone: Monitoring and management of side effects. https:// www.uptodate.com • Heidenreich, P. A., Estes, N. A., Fonarow, G.C., Jurgens, C. Y, Kittleson, M. M., & Marine, J. E. (2020). 2020 update to the 2016 ACC/AHA clinical performance and quality measures for adults with atrial fibrillation or atrial flutter. Circulatory Cardiovascular Quality Outcomes. https://doi.org/10.1161/HCQ.0000000000000100. • Hindricks, G. & Potpara, T. (2020). The ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European association for cardi-thoracic surgery (EACTS), European Heart Journal , 42, 373-498. https://doi.org/10.1093/eurheartj/ehaa612 • Honan, L. (2019). Focus on adult health: Medical-surgical nursing (2 nd ed). Wolters Kluwer.
• Kotecha, D., Lam, C., Van Veldhuisen, D. J., Van Gelder, I. C., Voors, A. A., & Rienstra, M. (2016). Heart failure with preserved ejection fraction and atrial fibrillation: Vicious twins. Journal of the American College of Cardiology, 68 (20), 2218-2227. https://doi.org/10.1016/j.jacc.2016.08.048 • Kumar, K. (2017). Antiarrhythmic drugs to maintain sinus rhythm in patients with atrial fibrillation: Recommendations. https://www.uptodate.com • McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8 th ed). Elsevier. • Morillo, C. A., Banerjee, A., Perel, P., Wood, D., & Jouven, X. (2017). Atrial fibrillation: The current epidemic. Journal of Geriatric Cardiology, 14 , 195-203. https://doi.org/10.11909/j.issn.1671-5411.2017.03.011 • Nesbitt, S. & Palomarez, R. E. (2016). Review: Increasing awareness and education on health disparities for health care providers. Ethnicity and Disease, 26 (2), 181-190. • Patel, R. B., Passman, R. S., & Shah, S.J. (2020). Embarking upon atrial fibrillation management in heart failure with preserved ejection fraction: Charting a course. Journal of Cardiovascular Electrophysiology , 31, 2284- 2287. https://doi.org/10.1111/jce.14635 • Pilgrim, J. (2018). Atrial fibrillation . Cinahl Information Systems. EBSCO Publishing. • Rosenthal, L. D. & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers . Elsevier. • Tanja, S. & Avital, O. (2021). Evidence-based care sheet: Atrial fibrillation . Cinahl Information Systems. EBSCO Publishing. • Walsh, K. & Caple, C. (2018). EKG series: EKG interpretation – Atrial fibrillation . Cinahl Information Systems. EBSCO Publishing. • Wigle, P., Hein, B., & Bernheisel, C. R. (2019). Anticoagulation: Updated guidelines for outpatient management. American Family Physician , 100 (7), 426-434. • Wong, C. X., Sullivan, T., Sun, M. T., Mahajan, R., Pathak, R. K., Middeldorp, M., Twomey, D., Ganesan, A. N., Rangnekar, G., Roberts-Thomson, K. C., Lau, D. H., & Sanders, P. (2015). Obesity and the risk of incident, post-operative, and post-ablation atrial fibrillation. JACC: Clinical Electrophysiology , 1 (3), 139-152. https://doi. org/10.1016/j.jacep.2015.04.004
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