Maintenance of sinus rhythm is always more important than rate control.

False. Traditionally, maintenance of sinus rhythm is regarded as superior to rate control in terms of long term outcome. However, studies in recent years have shown that anticoagulation is the most important therapy in preventing stroke in patients with AF. In patients with risks factors for stroke (age>75years, history of stroke/ TIA, hypertension, hypertension and heart failure), anticoagulation is needed for both rhythm and rate control strategies. Nonetheless, treatment plan should be individualized. Cardioversion is probably still indicated, at least once, in patients with newly onset AF. This is particularly true in situations where AV synchrony is important, e.g. in patients with congestive heart failure.

Back to top

3 weeks of anticoagulation is the norm prior to electrical cardioversion.

False. The ACUTE trial had clearly verified the equivalence of the TEE (transesophageal echocardiogram) approach and conventional anticoagulation approach before cardioversion. With the TEE approach, patients without evidence of thrombus on TEE received cardioversion immediately under cover with IV heparin without the conventional 3 weeks of anticoagulation therapy. At eight weeks of follow up, there was no difference in the embolic rates, deaths, maintenance of sinus rhythm and functional status. However, it should be noted that all patients in both groups received anticoagulation for eight weeks after cardioversion because atrial stunning may persist for a few weeks after cardioversion.

Back to top

True. In the CTAF (Canadian Trial of Atrial Fibrillation) and AFFIRM trials (The Atrial Fibrillation Followup Investigation of Rhythm Management), patients on amiodarone are more likely (69% and 62%) to stay in sinus rhythm when compared with other regimes (such as class I agents). However, the long-term side effects of amiodarone are a major consideration for its routine use. On the other hand, the efficacy rate of Sotalol and other class I drugs are in the range of 23% to 39% only.

Back to top

False. Digoxin is effective in controlling the ventricular response of AF at rest but not during exercise. A combination of beta-blocker (such as atenolol 50mg) with digoxin is the most effective approach with the combined use of digoxin and diltiazem the next choice. If rate control failed with appropriate medications, the next therapy that could be considered is AV nodal radiofrequency ablation and pacemaker placement. It has been shown that this technique preserved exercise tolerance and ejection fraction as effective as medical therapy and was marginally more effective in relieving symptoms and improving quality of life.

Back to top

References:
1. AFFIRM study. New Engl J Med. 2002;347:825-33.
2. ACUTE trial. New Engl J Med. 2001;344:1411-20.
3. CTAF trial. New Engl J Med. 2000;342:913-20.
4. Farshi et al. Ventricular rate control in chronic atrial fibrillation during daily activity and programmed exercise. J Am Coll Card 33 ;1999:304-310.

What are these skin lesions and what is the most likely cause in this patient?

The skin lesions are striae. They are most likely due to topical corticosteroid contained in the over-the-counter preparation used by the patient.

Back to top

What are the other common causes of the skin lesions?

The other common causes include rapid weight gain, accelerated growth and pregnancy. The common factor is due to an increase in volume or weight not balanced by a comparable enlargement of skin surface. This leads to excessive stretching or distension of skin. Apart from physiological conditions, striae can also occur in endocrine disorders such as Cushing syndrome.

Back to top

What are the common sites of involvement seen in otherwise normal individuals?

The striae occurring in normal individuals are also known as physiological striae. They are commonly found on the buttocks, thighs, back, abdomen, and breasts.

Back to top

What are the main histological features?

In early stage, there is fragmentation of collagen. An increase of elastic fibres occurs in chronic striae.

Back to top

What are the possible treatments?

The underlying cause/s should be identified and treated. So far, an effective treatment is still not available. Topical tretinoin and laser therapies have been tried with varying success but further studies are required to document their efficacy.

Back to top