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Original Question
Case 1: Episodes of atrial fibrillation after MI: A 56-year-old man is evaluated in the hospital for paroxysmal episodes of atrial fibrillation. The patient develops increasing shortness of breath during these episodes. Five days ago, he was admitted for an acute myocardial infarction and cardiogenic shock and received a drug-eluting stent in the left anterior descending coronary artery. Medications are lisinopril, digoxin, furosemide, aspirin, clopidogrel, eplerenone, simvastatin, and unfractionated heparin. On physical examination, the patient is afebrile, blood pressure is 92/65 mm Hg, and pulse rate is 75/min. Oxygen saturation is 95% with 3 L oxygen by nasal cannula. Cardiac examination reveals estimated central venous pressure of 12 cm H2O. Heart sounds are distant and regular. There is a grade 2/6 holosystolic murmur at the cardiac apex. A summation gallop is present. Crackles are auscultated bilaterally in the lower lung fields.Transthoracic echocardiogram shows left ventricular ejection fraction of 32%. Which of the following is the most appropriate treatment for this patient’s atrial fibrillation? A. Amiodarone B. Disopyramide C. Dronedarone D. Flecainide E. Sotalol Case 2: Dizziness, shortness of breath, and afib : A 76-year-old woman is evaluated in the emergency department for dizziness, shortness of breath, and palpitations that began acutely 1 hour ago. She has a history of hypertension and heart failure with preserved ejection fraction. Medications are hydrochlorothiazide, lisinopril, and aspirin. On physical examination, she is afebrile, blood pressure is 80/60 mm Hg, pulse rate is 155/min, and respiration rate is 30/min. Oxygen saturation is 80% with 40% oxygen by face mask. Cardiac auscultation reveals an irregularly irregular rhythm, tachycardia, and some variability in S1 intensity. Crackles are heard bilaterally one-third up in the lower lung fields.Electrocardiogram demonstrates atrial fibrillation with a rapid ventricular rate. Which of the following is the most appropriate acute treatment? A. Adenosine B. Amiodarone C. Cardioversion D. Diltiazem E. Metoprolol 3. Using IV Amiodarone, provide the IV bolus dose for this patient. B) What is the drug of choice for Ventricular Tachycardia? C) List the Class I, II, III, and IV Anti-Arrhythmic Agents. 4. Using IV Amiodarone 900 mg/500 ml NS, provide the IV maintenance dose infusion in ml/hr for the next 24 hours using the standard Amiodarone maintenance infusion. John is a, 61year old white male pt, who was awaken by substernal chest pain this morning and continues to experience chest pain as his wife is taking him to his Drs office. He was previously released from the Rehab hospital 2 weeks ago after recovering from a Stroke 4 weeks ago. His BP is 195/110 on arrival and his HR is 110 bpm. The following results are obtained: Fasting lipid profile: total cholesterol 240 mg/dL, HDL 30 mg/dL, LDL= 190, triglycerides 150 mg/dL fasting glucose 168 mg/dL; HbA1c= 8.5, Na= 138, K= 4.1, Hb= 14, Hct= 40, PLTs= 320 Wt. 100 KG. He is given SL Nitro 0.4 mg x 3 doses, 325 mg of Chewable Aspirin, Morphine 2 mg iv q 15 minutes as needed for chest pain, and Hi Flow nasal canula O2 at 5 liters/minute. 12 Lead EKG: Positive for ischemic angina, Troponin= 76.2 and CK MB= 245. EKG= ST Segment depression. 5. Provide and list the most optimal non pharmacologic and pharmacologic management and medication therapy recommended in the management of John’s acute chestpain based on his Past Medical History and comorbid conditions of hypertension, Diabetes, and CAD. Please provide weight based specific treatment where applicable.
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