,M. J=3(J.. since suggested to me by J. M. Thresher, of this city,. its gelatinous nature wellbutrin insomnia ambien milk of magnesia when applied to the. A more recent article on atrial fibrillation is available. DANA E. KING wellbutrin insomnia ambien M.D., LORI M. DICKERSON, PHARM.D., and JONATHAN L. SACK, M.D. Family physicians should be familiar with the acute management of atrial fibrillation and the initiation of chronic therapy for this common arrhythmia. Initial management should include hemodynamic stabilization, rate control, restoration of sinus rhythm, and initiation of antithrombotic therapy. Part II of this two-part article focuses on the prevention of thromboembolic complications using anticoagulation. Heparin is routinely administered before medical or electrical cardioversion. Warfarin is used in patients with persistent atrial fibrillation who are at higher risk for thromboembolic complications because of advanced age, history of coronary artery disease or stroke, or presence of left-sided heart failure. Aspirin is preferred in patients at low risk for thromboembolic complications and patients with a high risk for falls, a history of noncompliance, active bleeding, or poorly controlled hypertension. The recommendations provided in this article are consistent with guidelines published by the American Heart Association and the Agency for Healthcare Research and Quality. Although comorbid conditions such as hypertension and vascular disease are factors, the predominant cause of strokes in patients with atrial fibrillation is embolization of a clot from the left atrium. When evaluated using transesophageal echocardiography, up to 30 percent of patients with atrial fibrillation and embolic stroke are found to have atrial thrombi within 72 hours of the stroke.3,4 Risk factors for stroke in patients with atrial fibrillation include a history of transient ischemic attack or stroke, age greater than 65 years, a history of hypertension, the presence of a prosthetic heart valve , rheumatic heart disease, left ventricular systolic dysfunction, or diabetes. Heparin is the preferred agent for initial anticoagulation because it provides almost immediate effects and can be discontinued rapidly if bleeding complications arise.5 The drug should be given as a continuous intravenous infusion, with the dose titrated to achieve an activated partial thromboplastin time of 1.5 to 2.5 times the baseline value. In patients with atrial fibrillation that has persisted for more than 48 hours, heparin can be used to reduce the risk of thrombus formation and embolization until the warfarin level is therapeutic or cardioversion is performed. Prevention of deep venous thrombosis and pulmonary embolism are potential added benefits of initial anticoagulation with heparin. Warfarin therapy is monitored using the International Normalized Ratio . Therefore, it is important to consider risk versus benefit before warfarin is prescribed. Risk factors for major bleeding include poorly controlled hypertension, propensity for falling, dietary factors, interactions with concomitant medications, and difficulty controlling the degree of anticoagulation because of patient noncompliance.9,10 To ensure efficacy and minimize harm, the INR should be kept between 2.0 and 3.0. Other antiplatelet agents, such as ticlopidine , have not been studied in the prevention of embolic strokes in patients with atrial fibrillation. Hence, they are not recommended for use in these patients. Information from references 2, 9, and 10. Information from references 2, 9, and 10. INR = International Normalized Ratio. Information from references 2, 9, and 10. INR = International Normalized Ratio. Information from references 2, 9, and 10. If cardioversion is unsuccessful and patients remain in atrial fibrillation, warfarin or aspirin may be considered for long-term prevention of stroke. If atrial fibrillation recurs or patients are at high risk for recurrent atrial fibrillation, warfarin may be continued indefinitely, or aspirin therapy may be considered. Factors that increase the risk of recurrent atrial fibrillation include an enlarged left atrium and left ventricular dysfunction. Factors that significantly increase the risk for stroke include previous stroke, previous transient ischemic attack or systemic embolus, hypertension, poor left ventricular systolic function, age greater than 75 years, prosthetic heart valve, and history of rheumatic mitral valve disease. With persistent atrial fibrillation, patients older than 65 years and those with diabetes are also at increased risk. The lowest risk for stroke is in patients with atrial fibrillation who are less than 65 years of age and have no history of cardiovascular disease, diabetes, or hypertension. Heparin therapy should be considered in hospitalized patients with atrial fibrillation persisting beyond 48 hours and in patients undergoing medical or electrical cardioversion. Antithrombotic therapy using warfarin should be given for 3 weeks before cardioversion and 4 weeks after successful cardioversion. Patients with persistent or recurrent atrial fibrillation after attempted cardioversion should be given chronic warfarin or aspirin therapy for stroke prevention. Information from references 2, 9, and 10. Heparin therapy should be considered in hospitalized patients with atrial fibrillation persisting beyond 48 hours and in patients undergoing medical or electrical cardioversion. Antithrombotic therapy using warfarin should be given for 3 weeks before cardioversion and 4 weeks after successful cardioversion. Patients with persistent or recurrent atrial fibrillation after attempted cardioversion should be given chronic warfarin or aspirin therapy for stroke prevention. Information from references 2, 9, and 10. To see the full article, log in or purchase access. The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported. All comments are moderated and will be removed if they violate our Terms of Use. 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More progress this week! Our hard-working landscapers have completed the irrigation install and laid down soil in the landscaping beds. Inside, the electrician is finishing up some details related to our mechanical permit and it was signed off yesterday! Of course, we’ve also been getting the building ready for the final inspection, which includes creating…


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