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Điều trị rung nhĩ

 Case #1: A 62-year-old man presents to your clinic for a routine follow-up for atrial fibrillation (AF). He has stable, chronic coronary artery disease (CAD), left ventricular ejection fraction (LVEF) 55%, hypertension, and hyperlipidemia. AF was diagnosed 2-3 months ago when the patient presented with palpitations and mild dyspnea. Sotalol and warfarin were prescribed. The patient now denies palpitations or exercise limitations. A Holter monitor demonstrates approximately 3-4 hours of AF occurring a couple of times per week.

Which of the following is the best overall measure of successful therapy in this patient?

Resolution of palpitations

Quality of life

Decreased time spent in AF

Improvement in survival

Lack of heart failure symptoms

Which of the following drugs should be avoided due to the possibility of adverse effects in this particular patient?

Flecainide

Amiodarone

Dofetilide

Dronedarone

Case #1 (cont): Six months later this patient experiences recurrent palpitations and is changed to dronedarone.

Which of the following statements accurately describes the findings of the ATHENA trial, related to patients with nonpermanent AF?

Dronedarone was associated with an increased risk of ischemic stroke

Dronedarone demonstrated a trend toward benefit in reducing time in AF, but this finding was not significant

Dronedarone caused harm to patients with nonpermanent AF, compared with placebo

Dronedarone was significantly effective in reducing the combined primary endpoint of hospitalization and death

Case #2: A 78-year-old woman presents to your office with a history of palpitations over the past couple of days. She has a history of an anterior myocardial infarction (MI) several years ago, and her EF is known to be 35%. She has been stable New York Heart Association (NYHA) class 2. An ECG demonstrates new onset AF (heart rate [HR] = 90 bpm). The patient is a reasonable candidate for warfarin, and she wishes to discuss all of the options for therapy for her AF. The patient is started on amiodarone.

Which of the following is the most worrisome potential side effect of amiodarone?

Pulmonary toxicity

Acute kidney injury

Sleep apnea

Intestinal malabsorption

Case #2 (cont): At 6 months follow-up, the patient reports experiencing photosensitivity and disturbing dreams. She also has a recurrence of palpitations related to AF.

Which of the following statements describes the most appropriate strategy for discussing and selecting AF therapies with a patient?

Specific drug characteristics and side effects should be discussed directly with the patient and tailored to the situation

Only antiarrhythmic drugs that confer a survival benefit should be discussed with the patient

Catheter ablation should be considered first-line therapy in most situations

The proper dialogue should include information about the superiority of rhythm control over rate control

Which of the following is an accurate description of the CCS-SAF scale in atrial fibrillation?

The scale estimates the stroke risk for a patient over 1 year

The scale assesses the likelihood of side effects from antiarrhythmic drugs used to treat AF

The scale provides an approximation of success for catheter ablation for AF over 1 year

The scale evaluates symptom severity and quality of life for patients with AF

Guidelines currently recommend which of the following strategies for the use of catheter ablation?

Catheter ablation should be considered only for patients with congestive heart failure (CHF) and EF < 35%

Catheter ablation may be considered as second-line therapy if appropriate antiarrhythmic agents are unsuccessful

Catheter ablation should be considered primarily for patients with left atrial size > 5 cm

Catheter ablation is mostly still considered an experimental therapy and is not routinely recommended

Which of the following do you consider the most significant barrier to optimal management of patients with AF?

Difficulty in assessing quality of life in AF patients

Lack of time to fully discuss therapeutic options with AF patients

Numerous side effects of drugs

Lack of understanding of how to best measure treatment success

Uncertainty about when to refer for catheter ablation

Lack of patient adherence to therapy

Please indicate how relevant this CME activity is to your practice: approximately how many patients per week do you see with AF?

0

1-20

21-40

41-60

61-80

81-100

> 100

Which of the following is the best overall measure of successful therapy in this patient?

 

 

 

 Your Colleagues Responded:

 

Resolution of palpitations

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 9%

 

Quality of life

Correct Answer

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 79%

 

Decreased time spent in AF

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 7%

 

Improvement in survival

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 2%

 

Lack of heart failure symptoms

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 3%

Which of the following drugs should be avoided due to the possibility of adverse effects in this particular patient?

 

 

 

 Your Colleagues Responded:

 

Flecainide

Correct Answer

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 73%

 

Amiodarone

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 18%

 

Dofetilide

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 6%

 

Dronedarone

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 3%

Which of the following statements accurately describes the findings of the ATHENA trial, related to patients with nonpermanent AF?

 

 

 

 

Dronedarone was associated with an increased risk of ischemic stroke

 

 

Dronedarone demonstrated a trend toward benefit in reducing time in AF, but this finding was not significant

 

 

Dronedarone caused harm to patients with nonpermanent AF, compared with placebo

 

 

Dronedarone was significantly effective in reducing the combined primary endpoint of hospitalization and death

Correct Answer

Which of the following is the most worrisome potential side effect of amiodarone?

 

 

 

 Your Colleagues Responded:

 

Pulmonary toxicity

Correct Answer

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 84%

 

Acute kidney injury

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 10%

 

Sleep apnea

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 4%

 

Intestinal malabsorption

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 2%

Which of the following statements describes the most appropriate strategy for discussing and selecting AF therapies with a patient?

 

 

 

 Your Colleagues Responded:

 

Specific drug characteristics and side effects should be discussed directly with the patient and tailored to the situation

Correct Answer

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 91%

 

Only antiarrhythmic drugs that confer a survival benefit should be discussed with the patient

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 1%

 

Catheter ablation should be considered first-line therapy in most situations

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 1%

 

The proper dialogue should include information about the superiority of rhythm control over rate control

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 7%

Which of the following is an accurate description of the CCS-SAF scale in atrial fibrillation?

 

 

 

 Your Colleagues Responded:

 

The scale estimates the stroke risk for a patient over 1 year

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 13%

 

The scale assesses the likelihood of side effects from antiarrhythmic drugs used to treat AF

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 22%

 

The scale provides an approximation of success for catheter ablation for AF over 1 year

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 5%

 

The scale evaluates symptom severity and quality of life for patients with AF

Correct Answer

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 59%

Guidelines currently recommend which of the following strategies for the use of catheter ablation?

 

 

 

 Your Colleagues Responded:

 

Catheter ablation should be considered only for patients with congestive heart failure (CHF) and EF < 35%

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 6%

 

Catheter ablation may be considered as second-line therapy if appropriate antiarrhythmic agents are unsuccessful

Correct Answer

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 87%

 

Catheter ablation should be considered primarily for patients with left atrial size > 5 cm

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 3%

 

Catheter ablation is mostly still considered an experimental therapy and is not routinely recommended

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 3%

Which of the following do you consider the most significant barrier to optimal management of patients with AF?

 

 

 

 Your Colleagues Responded:

 

Difficulty in assessing quality of life in AF patients

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 16%

 

Lack of time to fully discuss therapeutic options with AF patients

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 14%

 

Numerous side effects of drugs

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 50%

 

Lack of understanding of how to best measure treatment success

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 9%

 

Uncertainty about when to refer for catheter ablation

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 3%

 

Lack of patient adherence to therapy

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 9%

Please indicate how relevant this CME activity is to your practice: approximately how many patients per week do you see with AF?

 

 

 

 Your Colleagues Responded:

 

0

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 9%

 

1-20

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 65%

 

21-40

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 12%

 

41-60

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 5%

 

61-80

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 3%

 

81-100

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 3%

 

> 100

 

http://images.medscape.com/pi/features/instantpoll/poll-bar.gif 3%

 

 

Nguồn: Medscape Cardiology
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