AF Patient Management 2 — Questions and Answers
Question 1: A patient with AF and a CHAâ‚‚DSâ‚‚-VASc score of 3 is intolerant to warfarin. What is the most appropriate next step?
- Discontinue anticoagulation entirely
- Initiate a direct oral anticoagulant (DOAC) (Correct answer)
- Start aspirin monotherapy
- Perform left atrial appendage closure
Correct answer: Initiate a direct oral anticoagulant (DOAC)
DOACs such as apixaban, rivaroxaban, or dabigatran are preferred alternatives when patients cannot tolerate warfarin.
Question 2: Which finding on a 12-lead ECG is most characteristic of atrial fibrillation?
- Prolonged PR interval with narrow QRS
- Absence of distinct P waves with irregularly irregular rhythm (Correct answer)
- Delta waves preceding the QRS complex
- Sawtooth flutter waves at 300 bpm
Correct answer: Absence of distinct P waves with irregularly irregular rhythm
AF produces an irregularly irregular ventricular response with absent, organized P waves replaced by fibrillatory baseline activity.
Question 3: A 72-year-old with AF is started on amiodarone for rhythm control. Which monitoring is most critical at follow-up?
- Serum potassium every 6 months
- Thyroid function tests, liver enzymes, and pulmonary function (Correct answer)
- Renal function tests every 3 months
- Complete blood count monthly
Correct answer: Thyroid function tests, liver enzymes, and pulmonary function
Amiodarone has significant organ toxicity affecting the thyroid, liver, and lungs, requiring periodic monitoring of all three systems.
Question 4: When is elective cardioversion of AF generally safe without transesophageal echocardiography (TEE) guidance?
- When AF duration is confirmed less than 48 hours (Correct answer)
- When the patient has been on warfarin for at least 1 week
- When the ventricular rate is controlled below 80 bpm
- When the patient is under 60 years old
Correct answer: When AF duration is confirmed less than 48 hours
AF of less than 48 hours duration carries a low thromboembolic risk, allowing cardioversion without mandatory TEE to rule out atrial thrombus.
Question 5: A patient with AF develops a sudden drop in blood pressure and signs of hemodynamic instability. What is the immediate management?
- Urgent oral beta-blocker loading
- IV diltiazem infusion for rate control
- Synchronized direct current cardioversion (Correct answer)
- Initiate heparin anticoagulation and observe
Correct answer: Synchronized direct current cardioversion
Hemodynamically unstable AF requires immediate synchronized electrical cardioversion regardless of anticoagulation status.
Question 6: Which patient characteristic is NOT included in the CHAâ‚‚DSâ‚‚-VASc stroke risk scoring system?
- Age 65–74 years
- Female sex
- Left ventricular ejection fraction below 40% (Correct answer)
- Prior stroke or TIA
Correct answer: Left ventricular ejection fraction below 40%
CHA₂DS₂-VASc includes CHF (not specifically low EF), hypertension, age, diabetes, stroke history, vascular disease, and sex — not EF alone.
Question 7: A patient on dabigatran for AF needs emergency surgery within 2 hours. Which reversal agent should be used?
- Vitamin K (phytonadione)
- Idarucizumab (Praxbind) (Correct answer)
- Andexanet alfa (Andexxa)
- Fresh frozen plasma
Correct answer: Idarucizumab (Praxbind)
Idarucizumab is the specific reversal agent for dabigatran, a direct thrombin inhibitor, approved for emergency reversal.
AF Patient Management 2
A patient with AF and a CHAâ‚‚DSâ‚‚-VASc score of 3 is intolerant to warfarin.
What is the most appropriate next step?