1/3. warfarin therapy for an octogenarian who has atrial fibrillation.In north america, atrial fibrillation is associated with at least 75 000 ischemic strokes each year. Most of these strokes occur in patients older than 75 years of age. The high incidence of stroke in very elderly persons reflects the increasing prevalence of atrial fibrillation that occurs with advanced age, the high incidence of stroke in elderly patients, and the failure of physicians to prescribe antithrombotic therapy in most of these patients. This failure is related to the increased risk for major hemorrhage with advanced age, obfuscating the decision to institute stroke prophylaxis with antithrombotic therapy.This case-based review describes the risk and benefits of prescribing antithrombotic therapy for a hypothetical 80-year-old man who has atrial fibrillation and hypertension, and it offers practical advice on managing warfarin therapy. After concluding that the benefits of warfarin outweigh its risks in this patient, we describe how to initiate warfarin therapy cautiously and how to monitor and dose the drug. We then review five recent randomized, controlled trials that document the increased risk for stroke when an international normalized ratio (INR) of less than 2.0 is targeted among patients with atrial fibrillation. Next, we make the case that cardioversion is not needed for this asymptomatic patient with chronic atrial fibrillation. Instead, we choose to leave the patient in atrial fibrillation and to control his ventricular rate with atenolol. Later, when the INR increases to 4.9, we advocate withholding one dose of warfarin and repeating the INR test. Finally, when the patient develops dental pain, we review the analgesic agents that are safe to take with warfarin and explain why warfarin therapy does not have to be interrupted during a subsequent dental extraction.- - - - - - - - - - ranking = 1keywords = extraction (Clic here for more details about this article) |
2/3. Fracture of a circular mapping catheter after entrapment in the mitral valve apparatus during segmental pulmonary vein isolation.We report on the entrapment of a circular mapping catheter in the mitral valve apparatus during segmental pulmonary vein isolation. In an attempt to remove the catheter by using mild traction in combination with clockwise and counter-clockwise rotation, the circular part and the shaft of the catheter separated. The circular part could be removed without sequelae using a transseptally positioned vascular extraction nipper in combination with a basket catheter.- - - - - - - - - - ranking = 1keywords = extraction (Clic here for more details about this article) |
3/3. Unexpected atrial fibrillation during tooth extraction in a sedated elderly patient.A case is reported of unexpected atrial fibrillation in response to tooth extraction under intravenous sedation in a 70-yr-old patient with thoracic aneurysm of the aorta. atrial fibrillation developed after the additional injection of a 2% solution of lidocaine containing 1:200,000 epinephrine. After 20 min, the arrhythmia disappeared spontaneously. The arrhythmia was associated with insufficient analgesia for tooth extraction, epinephrine in the local anesthetic, decreased blood pressure, and the presence of cardiovascular disease. Even when a low concentration of epinephrine is employed, caution should be paid to development of unexpected cardiovascular reactions in elderly patients with severe cardiovascular disease. We conclude that an electrocardiogram, blood pressure device, and pulse oximeter should be used in high-risk patients in order to prevent and detect potentially dangerous cardiovascular emergencies, even if dental treatment is scheduled under local anesthesia.- - - - - - - - - - ranking = 6keywords = extraction (Clic here for more details about this article) |