Atrial Fibrillation

As of the time of this writing, I am a second-year internal medicine resident physician, and have been involved in the care of at least fifty patients (averaging nearly one patient per work week, a very conservative estimate) with Atrial Fibrillation (AFib), an abnormal heart rhythm.  According to MKSAP 17 Cardiovascular Medicine, it is the #1 most common sustained cardiac arrhythmia, or abnormal electrical activity of the heart.  Among people aged 40 years old and beyond, physicians expect a whopping 1 in 4 people to become afflicted with the arrhythmia.  It is indeed age-related, the older you get, the more likely you are to develop AFib.  This abnormal heart rhythm confers a 5x increased risk of stroke, and increased risk of heart failure and dementia.

Etiology

  • Reversible/Treatable:  hyperthyroidism, pulmonary embolism, and cardiac surgery.
  • Chronic Conditions:  uncontrolled hypertension, anatomical pathology of the heart itself, and obstructive sleep apnea.

Clinical Presentation

  • Palpitations
  • Lightheadedness/Dizziness
  • Chest pain
  • Syncope (loss of consciousness)
  • Shortness of breath
  • Low blood pressure (severe presentation, usually with advanced pathology including diastolic dysfunction or restrictive cardiomyopathy)
  • Asymptomatic (found incidentally)

It is also important to note that some patients may first arrive in the ER with heart failure signs and symptoms (lower extremity edema, JVD, and pulmonary crackles/rales due to a fluid overload state) secondary to tachycardia-related cardiomyopathy.

CLASSIFICATIONS:
  • First-detected-
  • Paroxysmal-  AFib that starts and stops spontaneously
  • Persistent-  7 days duration or more
  • Long-standing-  more than 1 year.

Acute Management

Whether the condition is acute or chronic, there are three goals:  PREVENT STROKE, CONTROL HEART RATE, RELIEVE SYMPTOMS.

ANTICOAGULATION – PREVENT STROKE
1.  Assess with CHADS-VASc Score
CHA2DS2-VASc score 0 = Aspirin or no therapy
Score 1 = none or ASA or oral anticoagulant
Score 2+ = Oral anticoagulant

2.  For Cardioversion:  if AFib<48hrs, anticoagulation not necessary; if AFib ?duration or >48hrs, patient needs 3 weeks of therapeutic anticoagulation prior to CV.  TEE can be performed alternatively – if negative, can do CV now.
AFTER CV, need anticoagulation for minimum of 4 weeks.

If the patient develops hypotension, myocardial ischemia, heart failure, perform immediate synchronized cardioversion regardless of duration of AFib.

atrial fibrillation w/rapid ventricular response (RVR)
  • A common pathological variant, wherein patient’s heart rate (HR) is greater than 100 bpm.
  • Immediate control will restore cardiac function and symptoms.
  • Target HR 60-110 (acutely)
  • HR control with:  metoprolol, esmolol (fast acting), diltiazem (most used at my institution), verapamil.
    • Add Digoxin for hard-to-control patients, or if heart failure too.
    • If evidence of “preexcited AFib,” procainamide is the drug of choice.
  • Avoid CCBs in patients with LV dysfunction.
  • Pharmacologic cardioversion (CV) without structural disease:  flecainide, propafenone, or ibutilide.

Long-Term Management

Anticoagulation – prevent stroke (4% risk per year with nonvalvular AFib without comorbidities)

  • Assess with CHADS-VASc Score
  • If the patient has high-risk features:  mitral stenosis, rheumatic heart disease, prior systemic embolism, prosthetic heart valve, left atrial appendage thrombus, HOCM — give anticoagulation regardless of score.
  • Choose either vitamin K antagonist or a NOAC.
  • Warfarin
    • Vitamin K antagonist
    • Target INR 2-3
    • Low cost
    • Good for both non-valvular and valvular AFib cases (mitral stenosis or mitral valve replacement)
  • Nonvalvular AFib, choose one NOAC agent (no INR monitoring):
    • Apixaban
      • superior to warfarin for stroke prevention, similar rate of GI bleeding.
    • Rivaroxaban
      • Less intracranial and fatal bleeding c/w warfarin, but higher risk of GI bleeding c/w warfarin.
      • ONCE daily dosing
    • Dabigatran
      • superior to warfarin for stroke prevention, less intracranial bleeding but has higher GI bleeding risk.
    • All NOACs are renally-excreted (therefore, dose adjust).
  • If patient has had an acute coronary syndrome or revascularization within 12 months:
    • Administer low-dose Aspirin + oral anticoagulation
  • If patient got a coronary stent:
    • ASA + Plavix + anticoagulant for 6-12 months (for DES).
  • NO survival advantage or stroke reduction when comparing rate vs. rhythm control!
  • Usually start with rate control (BB or nondihydropyridine CCBs).
  • If still symptomatic, can try rhythm control regimen.
    • Cardioversion followed by anti-arrhythmic therapy.
    • “Pill-in-the-pocket” (flecainide or propafenone) only when develop an episode of AFib.  For infrequent AFib without other structural or conductive heart disease.  Should first be supervised.
  • Catheter ablation if refractory to above modalities (e.g. pulmonary vein isolation).
    • Anticoagulation for 2-3 months after ablation.

 

Bibliography

ACP MKSAP 17:  Cardiovascular Medicine, pp. 55-58

PGY-2 Life And Decisions

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In front of the North Tower on my last day of intern year!

It’ll take some time to shake the feeling of being the “Intern” after twelve months with that role.  One of my primary goals for intern year (first year) was to learn the fundamentals of real-world medical practice.  If I had to choose a few from a long-list, some fundamentals would include:  recognize life-threatening and other urgent but common conditions, treatment, and speaking to patients and families about their diseases, treatment, and prognosis.

It does feel good to officially be a PGY-2, or “senior” resident. Good and a little scary, to be honest.  I’m sincerely looking forward to the challenges that’ll come with being a senior resident on wards teams, ICU, and all of my elective rotations this academic year.  To help keep me focused on some of my top priorities, I’ve listed some areas I’d like to emphasize…

 

Research projects

  • Get going early this academic year, and aim to publish 2-3 different papers/works.
  • Work with a variety of mentors to gain insight/exposure.

Confidence

  • Make decisions confidently, knowing that I’ve (hopefully) had time to pre-read on the disease process/treatment/prognosis.

Keep an open mind

  • Continuously reassess my strengths and weaknesses; read & study daily whether that is UpToDate/MKSAP during spare time in the hospital and (for bonus study points) a few important sections daily at home.
  • Allow each new elective rotation to shape my future practice of medicine and career choices (e.g. fellowship options).

Ultimate goals

  • I do not know whether I want to end up in general medicine or sub-specialize just yet, but am leaning towards the latter.  Although I know in my heart the areas within Internal Medicine I enjoy most – Cardiology, Gastroenterology, and Musculoskeletal systems – I must decide on my ultimate career path no later than September 2016.
  • Sticking to a self-imposed deadline will allow my nearly daily struggle to decide on a possible fellowship path to come to a conclusion.  If I end up going the fellowship route post-IM residency, I really intend on going straight from residency to fellowship to maintain formal education continuity.

PGY-1 “Intern” Year In Review

It’s time for the obligatory “year in review” post, and I couldn’t be more proud.  Intern year is an emotional rollercoaster, marked by episodes of triumph and failure.  The year is almost over, and I am (anxiously) awaiting my second year of residency training.  Finishing intern year (first year) is a huge milestone in my professional medical career.  Many medical students ask me:  “Any advice for my first year of residency?”  My answer:  The learning curve is supremely steep; the first few months – really the entire twelve months – are extraordinarily difficult no matter your rank within your medical school class.  Personally, I worked hard to maintain a top ranking position within my med school class, but still felt the full burden of the many lessons that intern year teaches.

Dr. ________, (you) are responsible for official-record documentation

From Day 1, most specialties require new baby doctors, aka “Interns,” to be responsible for patient History & Physical’s and Progress notes.  These are the real-deal.  Gone are the days that your medial student notes are reviewed by the resident or faculty mentor and then set aside for your next practice H&P/progress note.  Other physicians, residents, and nurses will read your documentation and you will be judged accordingly.

Dr. ________, can patient in room 618 eat?

I was asked this question during my first official pre-rounds on adult wards.  I had no idea if the patient could eat and had to consult with my senior resident.  You as the new intern will be asked this simple, yet important, question.  Answering wrong means the vascular surgeon won’t be able to operate as scheduled.  Your patient could continue to suffer and your consultant surgeon won’t be happy.  Synthesizing pertinent data points is no easy task for a baby doctor, but you will learn quickly.  Trust your seniors to help you early on, and remember your cases.

Patient in ED bed 23 needs something for pain.

Many rising PGY-2’s will probably agree that the first days of intern year are scary in that YOU are now responsible for some of the orders (and likely all of the orders as your PGY-1 year progresses).  Every medication has its therapeutic (good) effects and adverse effects (some potentially deadly!).  I’ll never forget some of the very first few pages I got from floor and ER nurses asking me for medication orders.  For IM, the very long list includes pain control, blood pressure reduction, fast heart rate control.  A ubiquitous order request is for pain control.  Everyone, including the layperson, is aware of some of the deadly effects of opiate pain killers.  Yet, as an internal medicine, surgical, etc. intern, you’ll be asked to evaluate a variety of cases that require high-intensity pain control medications.  This happens month one of residency.  This is another instance where your senior will help guide you, in most cases.  It’s scary yes, but be prepared for it and you’ll get through it too!

Summary

Intern year was amazing.  I love Internal Medicine.  It’s a cerebral specialty – your thinking will either positively, neutrally, or negatively affect your patient’s wellbeing.  That’s powerful.  The learning curve from medical student to intern year (first year of residency) is STEEP.  Just when you feel you know everything about Atrial Fibrillation with Rapid Ventricular Rate, you’ll be presented with a new patient who hosts a complex medical history and be forced to rethink how to care for this particular patient.  Other specialties are not dissimilar; I enjoy talking to everyone about ways they’ve needed to evolve their thinking.

Intern year = baby doctor learning the basics of the basics, lessons required to become an independently practicing doctor.

Millennial Doctors and Social Media

I’m part of the “Millennials” class of physicians.  Depending on the source you read, it’s generally characterized as people born between the years 1982-2004, give or take a couple years on either end of that date range.  We’re learning a great deal from our senior medical professionals, also known as Attendings.  These are our predecessors – the mentors we look up to, to learn the bread and butter techniques as well as secrets of the trade.  Like many other resident doctors, I still rely heavily on traditional methods of learning, including textbooks and question banks, but there is another movement afoot.

That movement – albeit a slow movement – is physicians learning and discussing healthcare topics online (examples on Twitter:  #meded, #hcsm, #FOAM).  Hashtag it whatever you want, it’s essentially anyone in healthcare who spends time disseminating information about the trade – online.  Physicians play a key role in healthcare, however I still feel (anecdotally speaking) that we are lagging behind a bit.  There are but just a few active residents and fellows on Twitter.  This leaves a large void in the social media world.

Prominent online physician presences like KevinMD illustrate why it’s important for doctors to at least establish a footprint online, and I agree.  It’s the norm; people look to our social media profile(s) for more about us.  The articles, comments, photos, and videos we post today may influence a patient to come see us in hospital A or clinic Z; a high school student to consider pre-medicine; a premed student to continue on the grueling path and get accepted into medical school; a medical student to choose a specialty and strive for the residency program of choice; and a resident to learn more about a sub-specialty field.  The opportunities to influence are numerous and far too many for me to account in one simple blog post.

I actively search and link to other young physicians on Twitter.  I enjoy reading posts in my spare time, whether those are micro-updates on Twitter to full-length articles and blog posts on reputable websites.  It keeps me updated on things that are happening within my profession across the U.S. and World in real-time.  The beauty of the modern world is that we have so many efficient ways to talk to one another; it is unprecedented.  So, let’s use this powerful technology to help other people.  It can be other doctors, PAs, NPs, registered nurses, or the general public – physicians should feel comfortable in their own professional online presence to educate and assist.