Being an outstanding physician and lifelong learner requires stoking the flames of clinical curiosity. In Chiefs’ Inquiry Corner (CIC) we attempt to succinctly answer actual clinical questions that have been raised on the wards and in the clinics of NYU’s teaching hospitals. Our answers are not meant to be all encompassing or practice changing but rather to serve as springboards for further exploration. For those of us with short attention spans, we hope CIC satisfies that craving for a morsel of knowledge in a digestible format.
Click to toggle the answers!
Conventionally, anticoagulation with warfarin has been the prefered method of stroke prevention in patients with valvular atrial fibrillation. In January 2019, the AHA/ACC/HRS Guidelines on the Management of Atrial Fibrillation clarified the definition of valvular a fib, restricting it to those with moderate to severe mitral stenosis or mechanical heart valve. In all other patients, direct oral anticoagulants (DOACs) are preferred.
References: A fib Guideline
In 1989, a small prospective study of patients undergoing coronary artery bypass graft, demonstrated a nearly 50% increase in perioperative pulmonary complications in patients who discontinued tobacco use within 8 weeks of surgery, compared to active smokers. This largely informed clinical practice, despite 5 other studies since that have not found a link between perioperative discontinuation of tobacco use and perioperative pulmonary complications. Due to the known negative impacts of active tobacco use on wound and bone healing, perioperative tobacco cessation can be recommended, but the optimal time interval is not yet known.
References: Perioperative Smoking Cessation
Dysphonia is a common complaint and affects a large number of people (one study cites a 30% cumulative lifetime risk). A careful history and physical exam is important in order to identify risk factors for underlying disorders that require urgent evaluation. However, even in the absence of a suspected serious underlying disorder, patients whose dysphonia fails to resolve or improve in 4 weeks should be referred for direct laryngoscopy.
References: Dysphonia Work Up