This one is odd. Our EM test-takers are over relying on familiarity with DOACs. The miss rate on it is 38% and it looks like a pretty easy recall type question.
You are explicitly told about the mitral stenosis, and have a textbook ECG presentation of AF.
And people keep answering (a) or (b).
But this is an example of guideline exclusions, which will be part of any certification exam.
The incorrect answers either confuse (or ignore) that mitral stenosis places the patient in the valvular AF group, calling for (c) Warfarin, which remains the standard of care. The first two answers are DOACs, which are indeed the “go-to” anticoagulants for nonvalvular AF.
No one answered “Aspirin”, which heightens our faith in humanity. 😀
Your stupid exam trick here is that if a question appears on the exam, and appears simple and textbook, look for issues that are testing deep knowledge of guidelines or standards of care. In this case, an explicit exclusion of DOACs in valvular AF.
The clinical knowledge being tested goes beyond the guidelines, and covers categorization of AF, and recall of the specifics of moderate-to-severe mital stenosis.
The image interpretation portion of the question is just exposure - unpredictable R-R intervals, irregular baseline showing choatic atrial activity, and no true P waves - AF.
This question appears in Med-Challenger Emergency Medicine Review with CME
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