David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
In general, patients with AF less than 48 hours in duration can be cardioverted without concern for embolism risk. Patients with AF lasting longer than 48 hours should be maintained with therapeutic anticoagulation for at least 3 to 4 weeks before cardioversion is attempted. A transesophageal echocardiogram showing the absence of left atrial thrombus can obviate the need for the 3 to 4 weeks of anticoagulation before cardioversion.
The CHA2DS2-VASc score should be used to determine which patients with nonvalvular AF should be treated with anticoagulant medications to prevent stroke. Patients with a score of 0 generally do not need anticoagulation; however, it is recommended for those with scores of 2 or higher. No treatment is required for patients with a score of 1, although use of aspirin or anticoagulation is sometimes reasonable for such patients.
Direct oral anticoagulants (DOACs) can be substituted for warfarin in patients with nonvalvular AF who have adequate renal function. These agents have been shown to be noninferior to warfarin for stroke prevention and have several therapeutic advantages (e.g., they do not require international normalized ratio monitoring and are associated with lower rates of intracranial hemorrhage).
Newer therapies for AF include radiofrequency catheter ablation (indicated for highly symptomatic patients in whom other treatments have failed) and mechanical occlusion of the atrial appendage (indicated when a nonpharmacologic approach to stroke prevention is preferred).
Metformin, if not contraindicated, remains the initial drug of choice for pharmacologic treatment of type 2 diabetes mellitus (T2DM). Metformin is considered safe for use in patients with an estimated glomerular filtration rate of 30 mL/min/1.72 m2 or greater.
If metformin alone does not result in adequate glycemic control over a period of a few months, providers should consider adding a second oral agent, a glucagon-like peptide-1–agonist, or basal insulin. Figure 1 in the article outlines medication recommendations for T2DM.
Hospitalists should consider initiating insulin in patients with newly diagnosed T2DM if they are symptomatic, have a hemoglobin A1c level of 10% or greater, or have blood glucose readings higher than 300 mg/dL.
Notable recent warnings from the U.S. Food and Drug Administration related to antidiabetic medications include the following: Sodium–glucose contransporter-2 inhibitors may be associated with ketoacidosis without significant hyperglycemia (“euglycemic” diabetic ketoacidosis), and saxagliptin and alogliptin may increase risk for congestive heart failure.
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Wesorick DH, Chopra V. Annals for Hospitalists - 18 April 2017. Ann Intern Med. ;166:HO1. doi: 10.7326/AFHO201704180
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Published: Ann Intern Med. 2017;166(8):HO1.
Cardiology, Hospital Medicine, Rhythm Disorders and Devices.
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