{"version":"1.0.0","segments":[{"startTime":0.0,"endTime":3.191,"body":"[intro music]"},{"startTime":3.191,"endTime":5.58,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.191,"endTime":5.58,"body":"to Harrison's Podclass"},{"startTime":5.58,"endTime":8.73,"body":"where we discuss important"},{"startTime":5.58,"endTime":8.73,"body":"concepts in internal medicine."},{"startTime":8.73,"endTime":9.85,"body":"I'm Cathy Handy."},{"startTime":9.85,"endTime":11.733,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.85,"endTime":11.733,"body":"Wiener and we're coming to you"},{"startTime":11.733,"endTime":14.291,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.83,"endTime":17.96,"body":"Welcome to Harrison's Podclass."},{"startTime":17.96,"endTime":21.41,"body":"Today's case is a 24-year-old"},{"startTime":17.96,"endTime":21.41,"body":"with palpitations."},{"startTime":21.41,"endTime":22.349,"body":"Morning, Cathy."},{"startTime":22.349,"endTime":23.182,"body":"[Dr. Handy] Hey Charlie."},{"startTime":23.182,"endTime":26.587,"body":"[Dr. Wiener] Okay so here today,"},{"startTime":23.182,"endTime":26.587,"body":"we have a 24-year-old woman,"},{"startTime":26.587,"endTime":29.41,"body":"comes to your office to"},{"startTime":26.587,"endTime":29.41,"body":"establish primary care."},{"startTime":29.41,"endTime":31.35,"body":"She recently immigrated from Myanmar"},{"startTime":31.35,"endTime":33.69,"body":"to start graduate school in your city."},{"startTime":33.69,"endTime":35.29,"body":"She grew up in a rural environment"},{"startTime":35.29,"endTime":36.6,"body":"and was generally healthy,"},{"startTime":36.6,"endTime":39.35,"body":"although her mother told her"},{"startTime":36.6,"endTime":39.35,"body":"she had rheumatic disease"},{"startTime":39.35,"endTime":40.69,"body":"as a child."},{"startTime":40.69,"endTime":43.63,"body":"She did not get any ongoing"},{"startTime":40.69,"endTime":43.63,"body":"medical care in Myanmar,"},{"startTime":43.63,"endTime":46.25,"body":"and she's never had any other episodes."},{"startTime":46.25,"endTime":47.58,"body":"On review of systems,"},{"startTime":47.58,"endTime":49.61,"body":"she does note that a few times a week,"},{"startTime":49.61,"endTime":53.07,"body":"she feels her heart racing"},{"startTime":49.61,"endTime":53.07,"body":"and that it seems irregular."},{"startTime":53.07,"endTime":54.98,"body":"These episodes can start most any time,"},{"startTime":54.98,"endTime":58.13,"body":"but are more common"},{"startTime":54.98,"endTime":58.13,"body":"during stress or exercise."},{"startTime":58.13,"endTime":61.0,"body":"If she's exercising and one"},{"startTime":58.13,"endTime":61.0,"body":"of these episodes starts,"},{"startTime":61.0,"endTime":63.57,"body":"she notes that she gets"},{"startTime":61.0,"endTime":63.57,"body":"very short of breath."},{"startTime":63.57,"endTime":67.04,"body":"They abate as she calms herself"},{"startTime":63.57,"endTime":67.04,"body":"down by doing meditation."},{"startTime":67.04,"endTime":69.73,"body":"So based on that history,"},{"startTime":67.04,"endTime":69.73,"body":"what do you think, Cathy?"},{"startTime":69.73,"endTime":71.63,"body":"[Dr. Handy] While not"},{"startTime":69.73,"endTime":71.63,"body":"prevalent in the United States,"},{"startTime":71.63,"endTime":74.22,"body":"rheumatic heart disease is"},{"startTime":71.63,"endTime":74.22,"body":"still a worldwide issue,"},{"startTime":74.22,"endTime":77.09,"body":"and that component of our"},{"startTime":74.22,"endTime":77.09,"body":"history should not be ignored."},{"startTime":77.09,"endTime":77.923,"body":"[Dr. Wiener] What do you mean?"},{"startTime":77.923,"endTime":79.1,"body":"[Dr. Handy] Well, rheumatic heart disease"},{"startTime":79.1,"endTime":80.69,"body":"can have long term consequences,"},{"startTime":80.69,"endTime":83.76,"body":"so even though many people"},{"startTime":80.69,"endTime":83.76,"body":"will get it as a child,"},{"startTime":83.76,"endTime":86.58,"body":"adult practitioners do"},{"startTime":83.76,"endTime":86.58,"body":"need to be aware of it."},{"startTime":86.58,"endTime":87.85,"body":"[Dr. Wiener] What things"},{"startTime":86.58,"endTime":87.85,"body":"are you worried about"},{"startTime":87.85,"endTime":91.12,"body":"and what specifically piques"},{"startTime":87.85,"endTime":91.12,"body":"your interest in this case?"},{"startTime":91.12,"endTime":93.67,"body":"[Dr. Handy] So it would predispose"},{"startTime":91.12,"endTime":93.67,"body":"her to valvular problems,"},{"startTime":93.67,"endTime":95.69,"body":"such as mitral stenosis,"},{"startTime":95.69,"endTime":98.01,"body":"arrhythmias, most notably"},{"startTime":95.69,"endTime":98.01,"body":"atrial fibrillation,"},{"startTime":98.01,"endTime":100.76,"body":"which could be contributing"},{"startTime":98.01,"endTime":100.76,"body":"to her symptoms now,"},{"startTime":100.76,"endTime":102.11,"body":"and she'll need to be evaluated"},{"startTime":102.11,"endTime":105.03,"body":"for prophylactic"},{"startTime":102.11,"endTime":105.03,"body":"antibiotics for procedures."},{"startTime":105.03,"endTime":107.39,"body":"Actually, the history that she"},{"startTime":105.03,"endTime":107.39,"body":"gives does sound suspicious"},{"startTime":107.39,"endTime":110.19,"body":"for paroxysmal or sustained"},{"startTime":107.39,"endTime":110.19,"body":"atrial fibrillation."},{"startTime":110.19,"endTime":111.8,"body":"Do you have her vital signs?"},{"startTime":111.8,"endTime":115.13,"body":"[Dr. Wiener] Yeah, she's"},{"startTime":111.8,"endTime":115.13,"body":"afebrile, her heart rate is 96,"},{"startTime":115.13,"endTime":117.32,"body":"but it is irregularly irregular."},{"startTime":117.32,"endTime":121.02,"body":"Her blood pressure's 110 over"},{"startTime":117.32,"endTime":121.02,"body":"65, her respiratory rate is 12,"},{"startTime":121.02,"endTime":123.93,"body":"and her oxygen saturation"},{"startTime":121.02,"endTime":123.93,"body":"is 98% on room air."},{"startTime":123.93,"endTime":127.37,"body":"[Dr. Handy] And physical exam,"},{"startTime":123.93,"endTime":127.37,"body":"in particular the cardiac exam?"},{"startTime":127.37,"endTime":130.33,"body":"[Dr. Wiener] Well, she has"},{"startTime":127.37,"endTime":130.33,"body":"normal jugular venous pressure,"},{"startTime":130.33,"endTime":134.12,"body":"but on cardiac auscultation,"},{"startTime":130.33,"endTime":134.12,"body":"you hear a loud S1,"},{"startTime":134.12,"endTime":136.78,"body":"and a soft opening snap after S2,"},{"startTime":136.78,"endTime":140.22,"body":"that is associated with a"},{"startTime":136.78,"endTime":140.22,"body":"low-pitched early diastolic murmur"},{"startTime":140.22,"endTime":142.2,"body":"that is heard best at the apex."},{"startTime":142.2,"endTime":143.98,"body":"The rest of her physical examination"},{"startTime":143.98,"endTime":145.89,"body":"is relatively unremarkable."},{"startTime":145.89,"endTime":149.27,"body":"She has clear lungs and no pedal edema."},{"startTime":149.27,"endTime":151.39,"body":"[Dr. Handy] Okay, so the"},{"startTime":149.27,"endTime":151.39,"body":"irregularly irregular"},{"startTime":151.39,"endTime":152.67,"body":"heart rhythm you described"},{"startTime":152.67,"endTime":154.71,"body":"is classic for atrial fibrillation,"},{"startTime":154.71,"endTime":156.2,"body":"and the murmur that you described"},{"startTime":156.2,"endTime":159.47,"body":"is what you would expect in"},{"startTime":156.2,"endTime":159.47,"body":"someone with mitral stenosis."},{"startTime":159.47,"endTime":161.55,"body":"What's the question being asked?"},{"startTime":161.55,"endTime":163.64,"body":"[Dr. Wiener] Okay, so the question asks,"},{"startTime":163.64,"endTime":166.773,"body":"you calculate her"},{"startTime":163.64,"endTime":166.773,"body":"CHA2DS2-VASc score as one."},{"startTime":166.773,"endTime":169.314,"body":"you calculate her"},{"startTime":166.773,"endTime":169.314,"body":"CHA2DS2-VASc score as one."},{"startTime":169.314,"endTime":172.286,"body":"She gets one point for"},{"startTime":169.314,"endTime":172.286,"body":"female sex characteristics."},{"startTime":172.286,"endTime":174.34,"body":"[Dr. Handy] Well, let me"},{"startTime":172.286,"endTime":174.34,"body":"just stop you for a moment,"},{"startTime":174.34,"endTime":176.72,"body":"because that score really"},{"startTime":174.34,"endTime":176.72,"body":"wouldn't apply to her."},{"startTime":176.72,"endTime":177.71,"body":"[Dr. Wiener] What do you mean, why not?"},{"startTime":177.71,"endTime":179.14,"body":"I thought that's how we determine risk"},{"startTime":179.14,"endTime":182.22,"body":"for anticoagulation in patients"},{"startTime":179.14,"endTime":182.22,"body":"with atrial fibrillation."},{"startTime":182.22,"endTime":184.02,"body":"[Dr. Handy] So patients"},{"startTime":182.22,"endTime":184.02,"body":"with atrial fibrillation"},{"startTime":184.02,"endTime":186.25,"body":"are at an increased"},{"startTime":184.02,"endTime":186.25,"body":"risk for embolic stroke,"},{"startTime":186.25,"endTime":188.09,"body":"which is why we think"},{"startTime":186.25,"endTime":188.09,"body":"about anticoagulation"},{"startTime":188.09,"endTime":189.33,"body":"in these patients."},{"startTime":189.33,"endTime":191.95,"body":"The CHA2DS2-VASc score quantifies the risk"},{"startTime":191.95,"endTime":195.49,"body":"for patients with common"},{"startTime":191.95,"endTime":195.49,"body":"non-valvular atrial fibrillation,"},{"startTime":195.49,"endTime":198.6,"body":"and helps decide who should"},{"startTime":195.49,"endTime":198.6,"body":"receive stroke prophylaxis"},{"startTime":198.6,"endTime":200.11,"body":"based on the score."},{"startTime":200.11,"endTime":201.15,"body":"The score gives points"},{"startTime":201.15,"endTime":203.22,"body":"for the presence of"},{"startTime":201.15,"endTime":203.22,"body":"congestive heart failure,"},{"startTime":203.22,"endTime":207.55,"body":"hypertension, age, a history"},{"startTime":203.22,"endTime":207.55,"body":"of prior stroke or TIA,"},{"startTime":207.55,"endTime":210.1,"body":"diabetes, vascular disease or sex,"},{"startTime":210.1,"endTime":211.87,"body":"and a higher score is associated"},{"startTime":211.87,"endTime":213.69,"body":"with a higher risk of embolic stroke,"},{"startTime":213.69,"endTime":215.81,"body":"and most people recommend"},{"startTime":213.69,"endTime":215.81,"body":"treatment in patients"},{"startTime":215.81,"endTime":218.63,"body":"who are really anything"},{"startTime":215.81,"endTime":218.63,"body":"other than low risk."},{"startTime":218.63,"endTime":221.2,"body":"But I will note that women"},{"startTime":218.63,"endTime":221.2,"body":"receive a point in the system"},{"startTime":221.2,"endTime":222.954,"body":"just based on sex alone."},{"startTime":222.954,"endTime":225.392,"body":"[Dr. Wiener] So why do you"},{"startTime":222.954,"endTime":225.392,"body":"say she does not fit into this"},{"startTime":225.392,"endTime":228.43,"body":"category and why should we not"},{"startTime":225.392,"endTime":228.43,"body":"be using this score on her?"},{"startTime":228.43,"endTime":230.56,"body":"[Dr. Handy] She has"},{"startTime":228.43,"endTime":230.56,"body":"valvular atrial fibrillation"},{"startTime":230.56,"endTime":232.35,"body":"from her mitral stenosis."},{"startTime":232.35,"endTime":234.22,"body":"Now, anticoagulation is warranted"},{"startTime":234.22,"endTime":236.04,"body":"for patients with mitral stenosis,"},{"startTime":236.04,"endTime":237.56,"body":"hypertrophic cardiomyopathy,"},{"startTime":237.56,"endTime":239.87,"body":"and those with a prior history of stroke,"},{"startTime":239.87,"endTime":242.3,"body":"really regardless of this score."},{"startTime":242.3,"endTime":244.95,"body":"[Dr. Wiener] Okay, so the"},{"startTime":242.3,"endTime":244.95,"body":"question goes on to ask,"},{"startTime":244.95,"endTime":248.1,"body":"which of the following represents"},{"startTime":244.95,"endTime":248.1,"body":"the appropriate approach"},{"startTime":248.1,"endTime":250.81,"body":"to stroke prevention in this patient?"},{"startTime":250.81,"endTime":251.87,"body":"And the options are,"},{"startTime":251.87,"endTime":255.92,"body":"A. arrange for immediate"},{"startTime":251.87,"endTime":255.92,"body":"cardioversion into sinus rhythm;"},{"startTime":255.92,"endTime":259.08,"body":"B. arrange amiodarone orally"},{"startTime":259.08,"endTime":262.51,"body":"and one week later arrange"},{"startTime":259.08,"endTime":262.51,"body":"an electrical cardioversion;"},{"startTime":262.51,"endTime":266.81,"body":"C. initiate aspirin 325 milligrams daily;"},{"startTime":266.81,"endTime":271.16,"body":"D. initiate apixaban five"},{"startTime":266.81,"endTime":271.16,"body":"milligrams twice daily;"},{"startTime":271.16,"endTime":273.81,"body":"or E. initiate warfarin."},{"startTime":273.81,"endTime":275.45,"body":"Some of these, based on"},{"startTime":273.81,"endTime":275.45,"body":"what you already said,"},{"startTime":275.45,"endTime":277.34,"body":"can be ruled out, but"},{"startTime":275.45,"endTime":277.34,"body":"let's go through them."},{"startTime":277.34,"endTime":279.55,"body":"[Dr. Handy] Okay, so"},{"startTime":277.34,"endTime":279.55,"body":"immediate cardioversion"},{"startTime":279.55,"endTime":281.88,"body":"and amiodarone can be ruled out,"},{"startTime":281.88,"endTime":284.42,"body":"those would not be applicable here"},{"startTime":284.42,"endTime":286.93,"body":"and we want to talk about anticoagulation."},{"startTime":286.93,"endTime":288.64,"body":"The other three choices are all related"},{"startTime":288.64,"endTime":290.24,"body":"to some sort of anticoagulation,"},{"startTime":290.24,"endTime":291.81,"body":"so let's talk about those."},{"startTime":291.81,"endTime":293.607,"body":"[Dr. Wiener] Well, warfarin"},{"startTime":291.81,"endTime":293.607,"body":"can be a pain for patients"},{"startTime":293.607,"endTime":294.882,"body":"to take and monitor."},{"startTime":294.882,"endTime":297.2,"body":"Would you go with that,"},{"startTime":294.882,"endTime":297.2,"body":"aspirin or apixaban?"},{"startTime":297.2,"endTime":298.31,"body":"[Dr. Handy] I would go with warfarin,"},{"startTime":298.31,"endTime":301.1,"body":"and that's the correct"},{"startTime":298.31,"endTime":301.1,"body":"answer in this case."},{"startTime":301.1,"endTime":303.55,"body":"Anti-platelet agents,"},{"startTime":301.1,"endTime":303.55,"body":"such as aspirin, alone"},{"startTime":303.55,"endTime":306.62,"body":"are generally not sufficient,"},{"startTime":303.55,"endTime":306.62,"body":"so we can rule that out,"},{"startTime":306.62,"endTime":308.92,"body":"and apixaban is used"},{"startTime":306.62,"endTime":308.92,"body":"for atrial fibrillation,"},{"startTime":308.92,"endTime":310.91,"body":"but would not be used in this patient."},{"startTime":310.91,"endTime":311.743,"body":"[Dr. Wiener] Why not?"},{"startTime":311.743,"endTime":313.91,"body":"[Dr. Handy] The major"},{"startTime":311.743,"endTime":313.91,"body":"options for anticoagulation"},{"startTime":313.91,"endTime":316.08,"body":"in non-valvular atrial fibrillation"},{"startTime":316.08,"endTime":318.149,"body":"are the antithrombin inhibitors,"},{"startTime":318.149,"endTime":321.87,"body":"dabigatran, the factor Xa"},{"startTime":318.149,"endTime":321.87,"body":"inhibitors, such as rivaroxaban,"},{"startTime":321.87,"endTime":323.62,"body":"apixaban and edoxaban,"},{"startTime":323.62,"endTime":326.17,"body":"and the vitamin K antagonist warfarin."},{"startTime":326.17,"endTime":328.84,"body":"In non-valvular atrial"},{"startTime":326.17,"endTime":328.84,"body":"fibrillation, warfarin"},{"startTime":328.84,"endTime":332.2,"body":"has been shown to reduce the"},{"startTime":328.84,"endTime":332.2,"body":"annual risk of stroke by 64%"},{"startTime":332.2,"endTime":333.61,"body":"compared to placebo,"},{"startTime":333.61,"endTime":337.23,"body":"and by 37% compared to"},{"startTime":333.61,"endTime":337.23,"body":"anti-platelet therapy."},{"startTime":337.23,"endTime":338.64,"body":"Patients with atrial fibrillation"},{"startTime":338.64,"endTime":339.96,"body":"with an increased risk of stroke"},{"startTime":339.96,"endTime":342.4,"body":"also have an increased risk"},{"startTime":339.96,"endTime":342.4,"body":"of venous thromboembolism"},{"startTime":342.4,"endTime":345.39,"body":"which appears to be lower"},{"startTime":342.4,"endTime":345.39,"body":"with oral anticoagulation."},{"startTime":345.39,"endTime":347.67,"body":"Now, the direct acting anticoagulants"},{"startTime":347.67,"endTime":349.76,"body":"like dabigatran, rivaroxaban,"},{"startTime":349.76,"endTime":352.78,"body":"apixaban, which is mentioned"},{"startTime":349.76,"endTime":352.78,"body":"in this case, and edoxaban,"},{"startTime":352.78,"endTime":355.9,"body":"were non-inferior to warfarin"},{"startTime":352.78,"endTime":355.9,"body":"in individual trials,"},{"startTime":355.9,"endTime":359.19,"body":"and analysis of pooled data"},{"startTime":355.9,"endTime":359.19,"body":"suggests superiority to warfarin"},{"startTime":359.19,"endTime":362.25,"body":"by absolute margins of less than 1%"},{"startTime":362.25,"endTime":363.9,"body":"in reduction of mortality, stroke,"},{"startTime":363.9,"endTime":366.46,"body":"major bleeding and"},{"startTime":363.9,"endTime":366.46,"body":"intracranial hemorrhage."},{"startTime":366.46,"endTime":367.64,"body":"But remember, those are patients"},{"startTime":367.64,"endTime":370.096,"body":"with non-valvular atrial fibrillation."},{"startTime":370.096,"endTime":371.59,"body":"[Dr. Wiener] So what about this patient"},{"startTime":371.59,"endTime":374.2,"body":"who has valvular disease"},{"startTime":371.59,"endTime":374.2,"body":"and atrial fibrillation?"},{"startTime":374.2,"endTime":375.73,"body":"[Dr. Handy] Warfarin is"},{"startTime":374.2,"endTime":375.73,"body":"the agent recommended"},{"startTime":375.73,"endTime":378.03,"body":"for patients with"},{"startTime":375.73,"endTime":378.03,"body":"rheumatic mitral stenosis"},{"startTime":378.03,"endTime":379.8,"body":"or mechanical heart valves."},{"startTime":379.8,"endTime":383.43,"body":"The newer direct-acting"},{"startTime":379.8,"endTime":383.43,"body":"anticoagulants have not been tested"},{"startTime":383.43,"endTime":384.65,"body":"in rheumatic heart disease,"},{"startTime":384.65,"endTime":386.37,"body":"and a direct thrombin inhibitor"},{"startTime":386.37,"endTime":388.09,"body":"did not prevent thromboemboli"},{"startTime":388.09,"endTime":390.17,"body":"in patients with mechanical heart valves."},{"startTime":390.17,"endTime":392.83,"body":"So that's why this patient"},{"startTime":390.17,"endTime":392.83,"body":"would be started on warfarin,"},{"startTime":392.83,"endTime":394.859,"body":"and not one of the newer agents."},{"startTime":394.859,"endTime":397.83,"body":"[Dr. Wiener] Okay great, so the"},{"startTime":394.859,"endTime":397.83,"body":"teaching point in this case,"},{"startTime":397.83,"endTime":399.66,"body":"are that patients with atrial fibrillation"},{"startTime":399.66,"endTime":401.98,"body":"are at increased risk of embolic stroke."},{"startTime":401.98,"endTime":403.89,"body":"Deciding which medications should be used"},{"startTime":403.89,"endTime":406.21,"body":"to reduce the risk of stroke"},{"startTime":403.89,"endTime":406.21,"body":"depends on whether or not"},{"startTime":406.21,"endTime":408.1,"body":"the patient has valvular heart disease"},{"startTime":408.1,"endTime":409.95,"body":"or non-valvular heart disease."},{"startTime":409.95,"endTime":412.2,"body":"In the absence of valvular heart disease,"},{"startTime":412.2,"endTime":414.21,"body":"the patient's level of"},{"startTime":412.2,"endTime":414.21,"body":"risk can be assessed"},{"startTime":414.21,"endTime":416.58,"body":"using the CHADS2-VASc score."},{"startTime":416.58,"endTime":418.34,"body":"In patients with valvular heart disease"},{"startTime":418.34,"endTime":419.48,"body":"and atrial fibrillation,"},{"startTime":419.48,"endTime":421.464,"body":"they should receive warfarin."},{"startTime":421.464,"endTime":422.74,"body":"[Dr. Handy] And you can"},{"startTime":421.464,"endTime":422.74,"body":"read more about this"},{"startTime":422.74,"endTime":425.231,"body":"in Harrison's chapter"},{"startTime":422.74,"endTime":425.231,"body":"on atrial fibrillation."},{"startTime":425.231,"endTime":427.473,"body":"[outro music]"},{"startTime":429.46,"endTime":432.237,"body":"[Mr. Shanahan] This is Jim"},{"startTime":429.46,"endTime":432.237,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":432.237,"endTime":433.96,"body":"Harrison's Podclass is brought to you"},{"startTime":433.96,"endTime":435.93,"body":"by McGraw Hill's Access Medicine,"},{"startTime":435.93,"endTime":437.43,"body":"the online medical resource"},{"startTime":437.43,"endTime":439.4,"body":"that delivers the latest trusted content"},{"startTime":439.4,"endTime":441.26,"body":"from the best minds in medicine."},{"startTime":441.26,"endTime":443.803,"body":"Go to accessmedicine.com to learn more."}]}