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AtrialFibrillation

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13

Safety of new oral anticoagulants

Two linked papers (doi:10.1136/bmj.h1857, doi:10.1136/bmj.h1585) report additional evidence on the risks of gastrointestinal bleeding among patients taking the novel oral anticoagulants dabigatran and rivaroxaban.1 2 From a database of more than 100 million US adults, Abraham and colleagues identified almost 220 000 new users of dabigatran, rivaroxaban, or warfarin between November 2010 and September 2013.1 In their comparison of propensity score matched patients, the risk of gastrointestinal bleeding increased significantly with age for both new oral anticoagulants, relative to warfarin. By age 75, the risk of gastrointestinal bleeding associated with rivaroxaban exceeded that with warfarin, for patients with or without atrial fibrillation. Among patients taking dabigatran, the association between older age and higher risk was confined to those with atrial fibrillation, although the data included very few patients without atrial fibrillation taking this drug.  
feeds.bmj.com
over 6 years ago
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0
15

Safety of new oral anticoagulants

Two linked papers (doi:10.1136/bmj.h1857, doi:10.1136/bmj.h1585) report additional evidence on the risks of gastrointestinal bleeding among patients taking the novel oral anticoagulants dabigatran and rivaroxaban.1 2 From a database of more than 100 million US adults, Abraham and colleagues identified almost 220 000 new users of dabigatran, rivaroxaban, or warfarin between November 2010 and September 2013.1 In their comparison of propensity score matched patients, the risk of gastrointestinal bleeding increased significantly with age for both new oral anticoagulants, relative to warfarin. By age 75, the risk of gastrointestinal bleeding associated with rivaroxaban exceeded that with warfarin, for patients with or without atrial fibrillation. Among patients taking dabigatran, the association between older age and higher risk was confined to those with atrial fibrillation, although the data included very few patients without atrial fibrillation taking this drug.  
feeds.bmj.com
over 6 years ago
Www.bmj
0
24

Safety of new oral anticoagulants

Two linked papers (doi:10.1136/bmj.h1857, doi:10.1136/bmj.h1585) report additional evidence on the risks of gastrointestinal bleeding among patients taking the novel oral anticoagulants dabigatran and rivaroxaban.1 2 From a database of more than 100 million US adults, Abraham and colleagues identified almost 220 000 new users of dabigatran, rivaroxaban, or warfarin between November 2010 and September 2013.1 In their comparison of propensity score matched patients, the risk of gastrointestinal bleeding increased significantly with age for both new oral anticoagulants, relative to warfarin. By age 75, the risk of gastrointestinal bleeding associated with rivaroxaban exceeded that with warfarin, for patients with or without atrial fibrillation. Among patients taking dabigatran, the association between older age and higher risk was confined to those with atrial fibrillation, although the data included very few patients without atrial fibrillation taking this drug.  
feeds.bmj.com
over 6 years ago
Static.www.bmj
0
13

Spontaneous hypokalaemia in a man with treated hypertension

An 80 year old man with a history of hypertension, stage 3 chronic kidney disease, and paroxysmal atrial fibrillation presented feeling generally unwell and lethargic. He was taking amiodarone 200 mg, bisoprolol 10 mg, amlodipine 10 mg, and lisinopril 20 mg a day. He did not have a fever and he was haemodynamically stable. His blood pressure was controlled (132/84 mm Hg). Physical examination was unremarkable. Blood tests showed hypokalaemia (1.9 mmol/L, reference range 3.5-5.0), hypomagnesaemia (0.58 mmol/L, 0.6-1.2), and metabolic alkalosis (35 mmol/L, 20-32). His symptoms resolved after electrolyte replacement and he was discharged home.  
feeds.bmj.com
over 6 years ago
Sinaiem dark
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8

slow-and-steady

75 y/o M with a past medical history of atrial fibrillation presents to the ED not feeling well for several days. He has some diarrhea but has continued to take his medications. He is mildly hypotensive. While IV access is established, you are shown his ECG….  
sinaiem.org
over 6 years ago
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1

KT Evidence Bite: Cardioversion and Thromboembolism - CanadiEM

What is the incidence of and risk factors for thromboembolic events after ED cardioversion of acute atrial fibrillation? Early cardioversion (<12hrs) is  
boringem.org
over 6 years ago
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10

The Case of the Irregular Irregularity - EM Nerd

We have proven ourselves highly capable of managing atrial fibrillation in the Emergency Department. In recent years, a number of prospective cohorts have demonstrated that with the use of IV anti-arrhythmic medication and electrical cardioversion, patients presenting to the Emergency Department with new onset atrial fibrillation can be successfully discharged in sinus rhythm consistently and with minimal adverse events. In 2010, Steill et al published a case series of 660 patients who were cardioverted in the Emergency Department (1). What they coined the “Ottawa Aggressive Protocol” consisted of chemically managed rate control followed by a trial of procainamide loaded over an hour and, if this failed to convert the patient, DC electrical cardioversion. Using this protocol, Steill et al cite the number of patients who were discharged home in normal sinus rhythm to be 595 (90.2%). In a recent systematic review published in the European Journal of Emergency Medicine, Coll-Vinent et al found that in patients who underwent Emergency Department cardioversion, 78.2%-100% were discharged home in a normal sinus rhythm (2).  
emnerd.com
over 6 years ago
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16

A 56 year old woman with syncope, weakness, and refractory hypotension

A 56 year old woman with hypothyroidism after total thyroidectomy presented to the emergency department after an episode of near syncope. When she arrived she had hypotension and atrial fibrillation, with a rapid ventricular response. She reported a history of progressive weakness, weight loss, polyuria, polydipsia, anorexia, and fatigue. Urine analysis was positive for leucocyte esterase and pyuria. She was admitted to the intensive care unit with a diagnosis of severe sepsis of urinary source and atrial fibrillation with a rapid ventricular response. After aggressive fluid resuscitation and the administration of intravenous antibiotics, her heart spontaneously converted to a normal rhythm and she appeared well perfused but remained hypotensive. Review of her medical record showed that her therapeutic thyroxine replacement had recently been decreased because of low thyrotrophin. On perusal of her records from an another facility it was noted that she had undergone pituitary mass resection and irradiation 20 years earlier.  
feeds.bmj.com
over 6 years ago
Www.bmj
0
20

A 56 year old woman with syncope, weakness, and refractory hypotension

A 56 year old woman with hypothyroidism after total thyroidectomy presented to the emergency department after an episode of near syncope. When she arrived she had hypotension and atrial fibrillation, with a rapid ventricular response. She reported a history of progressive weakness, weight loss, polyuria, polydipsia, anorexia, and fatigue. Urine analysis was positive for leucocyte esterase and pyuria. She was admitted to the intensive care unit with a diagnosis of severe sepsis of urinary source and atrial fibrillation with a rapid ventricular response. After aggressive fluid resuscitation and the administration of intravenous antibiotics, her heart spontaneously converted to a normal rhythm and she appeared well perfused but remained hypotensive. Review of her medical record showed that her therapeutic thyroxine replacement had recently been decreased because of low thyrotrophin. On perusal of her records from an another facility it was noted that she had undergone pituitary mass resection and irradiation 20 years earlier.  
feeds.bmj.com
over 6 years ago
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12

Patients can self monitor oral anticoagulation, study shows

The study, reported in the British Journal of General Practice, included 296 patients requiring oral anticoagulation who had bought a device to self monitor their international normalised ratio (INR). Most patients (97%) had warfarin prescribed, and this was for a range of conditions including thrombosis (35.8%), having a mechanical heart valve (32.8%), atrial fibrillation (23.0%), and …  
feeds.bmj.com
over 6 years ago
Www.bmj
0
19

Patients can self monitor oral anticoagulation, study shows

The study, reported in the British Journal of General Practice, included 296 patients requiring oral anticoagulation who had bought a device to self monitor their international normalised ratio (INR). Most patients (97%) had warfarin prescribed, and this was for a range of conditions including thrombosis (35.8%), having a mechanical heart valve (32.8%), atrial fibrillation (23.0%), and …  
feeds.bmj.com
over 6 years ago
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10

Journal Update - Beta Blocker vs. Calcium Channel Blocker for Rate Control in Atrial Fibrillation - R.E.B.E.L. EM - Emergency Medicine Blog

Is diltiazem or metroprolol the more effective agent for rate control in Atrial Fibrillation (AF) with RVR in the ED?  
rebelem.com
over 6 years ago
Www.bmj
0
7

Sudden onset double vision

An 83 year old woman was admitted to the acute stroke unit with sudden onset double vision that had lasted for three hours. She had a medical history of monoclonal gammopathy of uncertain significance and atrial fibrillation, for which she was not receiving anticoagulation because of an adverse reaction to warfarin. She had no history of transient ischaemic attack or stroke. She had diplopia only when looking through her right. On examination she was unable to adduct her left eye, with nystagmus in her right eye when she attempted to do this. Her neurological examination was otherwise normal. Computed tomography of the head on admission was normal, as was magnetic resonance imaging of the head, which was requested the next day. Figure 1⇓ shows T2 weighted (A) and diffusion weighted (B) sequences at the level of the upper pons.  
feeds.bmj.com
about 6 years ago
Www.bmj
0
18

Retrospective cohort studies: advantages and disadvantages

Researchers investigated whether differences exist between the sexes in the risk of ischaemic stroke in patients with atrial fibrillation.1 A nationwide retrospective cohort study design was used. Data were taken from the Swedish national discharge register. Participants were 100 802 patients with a first diagnosis of atrial fibrillation between 1 July 2005 and 31 December 2008, with a total follow-up of 139 504 years at risk (median 1.2). Information about drug treatment was taken from the Swedish drug register. Patients were excluded if at baseline they were prescribed warfarin, had mitral stenosis, or had previous valvular surgery. Patients who died less than 14 days from baseline were also excluded.  
feeds.bmj.com
about 6 years ago