Review Question - QID 211754

Atrial fibrillation (AF) is the most common cause of upper extremity thromboembolism and can be treated with anticoagulants by a cardiologist.

Acute non-traumatic hand ischemia has many potential causes and often requires a multidisciplinary approach to diagnose and treat. Up to 93% of acute upper extremity ischemia is from cardiac embolism. The most common cause of cardiac embolism is AF. Loss of atrial contractility and expulsion leads to stasis and thrombus development.

Zimmerman reviewed occlusive vascular disorders of the upper extremity. He discusses that arterial occlusive disease of the hand is usually secondary to posttraumatic occlusion of the ulnar artery. An embolic source is more likely in the setting of AF or following myocardial infarction, and venous occlusion is more likely when there is a hypercoagulable state.

Brinkley and Hepper review structural cardiac abnormalities that manifest as acute dysvascular conditions of the hand. They report that cardiomyopathy, valvular disease, atrial septal defects, and aortic arch abnormalities may all be associated with thromboembolism. However, the authors note that AF constitutes 80% of upper extremity thromboembolism.

Based on the 2014 AHA/ACC/HRS guideline for the management of patients with AF, those with any one high-risk factor or more than one moderate-risk factor should be treated with anticoagulation for non-valvular AF in addition to medication for heart rate control. The authors report that high-risk factors include prior stroke or transient ischemic attack, systemic thromboembolism, or age 75 years or older, while moderate-risk factors include age 65-74 years, female sex, hypertension, diabetes mellitus, heart failure, or arterial disease.

Incorrect Answers:
Answer 1: Ischemic cardiomyopathy, which may precipitate thromboembolism, may be treated with cholesterol medication.
Answer 2: Antiplatelet medication may be indicated for prophylaxis in patients with mechanical valves, which the patient does not have.
Answer 3: Antibiotics may be indicated in the setting of endocarditis, which can also precipitate septic thromboembolism.
Answer 4: A beta-blocker may control rate, but not rythm, so one is still at risk for thromboembolism.