Atrial fibrillation and flutter

Question 1

The most common sustained arrhythmia

Answer 1

Atrial Fibrillation

Question 2

Atrial Fibrillation - Risk Factors

Answer 2

■ Acute alcohol excess/”Holiday Heart” - Usually transient, self-limited
■ Pericarditis
■ Chest trauma or thoracic surgery
■ Thyroid disorders (thyrotoxicosis)
■ Obstructive Sleep Apnea
■ Pulmonary Embolism
■ COPD
■ Obesity
■ Some medications (theophylline, adenosine, digitalis, etc.)
■ Post-operative (cardiac surgery/catheterization)

Question 3

Risks of Untreated Atrial Fibrillation

Answer 3

1. Thrombus formation and embolization
2. Tachycardia à impaired LV filling
   - persistent tachycardia (weeks) can
   lead to cardiomyopathy and heart failure
3. Loss of the atrial kick

Question 4

Atrial Fibrillation - Pathophysiology

Answer 4

● Atrial fibrillation is a chaotic rapid, irregular atrial rhythm.
● It results from ectopic electrical signals mostly in the pulmonary veins of the left atrium.
● When these signals are conducted through the AV node the result is an irregular tachyarrhythmia

Question 5

When the heart is in A-Fib, stasis within the atria
occurs especially in the _____

Answer 5

Left atrial appendage

Question 6

Atrial Fibrillation - Presentation

Answer 6

■ Palpitations
■ Tachycardia
■ Hypotension
■ Fatigue (common) or weakness
■ Dizziness/lightheadedness
■ Dyspnea
■ Angina
■ Decreased exercise tolerance
■ Presyncope or (infrequently) syncope

Question 7

Atrial Fibrillation - vital signs

Answer 7

● A-Fib can present with slow, normal, or fast rates;
● If the HR is greater than 100, it is A-Fib with Rapid Ventricular Response (RVR)

Question 8

_____ - difference between apical rate and
pulse rate

Answer 8

Pulse deficit

Question 9

Atrial Fibrillation – Work Up & EKG findings

Answer 9

1. H&P
2. Electrocardiogram (EKG) establishes the diagnosis with
   characteristic findings:
   ● An Irregularly Irregular R-R Interval (no repetitive pattern)
   ● Fibrillatory waves replace discernable P waves

Question 10

What is this rhythm showing?

Answer 10

Atrial fibrilation
● An Irregularly Irregular R-R Interval (no repetitive pattern)
● Fibrillatory waves replace discernable P waves

Question 11

A-Fib often presents with ____

Answer 11

Rapid Ventricular Response, with a ventricular heart rate of 100 to 180 bpm (commonly around 120)

Question 12

_____ provides valuable information about the size and function of the atria and ventricles.

Answer 12

Echocardiogram

Question 13

Ancillary Testing for A-fib

Answer 13

■ Transthoracic Echo (TTE) is more commonly ordered.
■ Transesophageal Echo (TEE) is more sensitive for detection of
thrombi formation in the left atrium or left atrial appendage

Question 14

Atrial Fibrillation -Management of at risk patients

Answer 14

1. Lifestyle Modifications
   a. Modifying risk factors is FOUNDATIONAL

Question 15

Atrial Fibrillation -Management of those diagnosed with atrial fibrilation

Answer 15

1. Assess risk of stroke and implement treatments
2. Continue to optimize modifiable risk factors
3. Manage symptoms

Question 16

1. Primary Prevention of Atrial fibrilation

Answer 16

Modifications targeting: obesity,
sedentariness, unhealthy EtOH use, smoking,
diabetes and HTN
(1B recommendation)

Question 17

Secondary Prevention of atrial fibrilation

Answer 17

1. Weight loss target of at least 10% (1B)
2. Moderate to vigorous exercise target 210 mins/week (1B)
3. Smoking Cessation (1B)
4. Minimize/eliminate EtOH (1B)
5. Caffeine – eliminating showed no benefit
6. Optimal BP control (1B)
7. Screen for sleep apnea (2B)

Question 18

Validated scoring assessment for stroke risk

Answer 18

CHA 2 DS2 -VASC2

Question 19

When to start Direct oral anticoagulation (DOACs) vs. warfarin?

Answer 19

DOACs > warfarin for patients without history of moderate to severe
rheumatic mitral valve disease, or a mechanical valve (1A)
■ Or, valvular disease that is NOT listed above (1B

Question 20

When to start warfarin vs. DOACs for patients with A-fib

Answer 20

Warfarin >DOACs for patients with history of above independent of score
(1B)

Question 21

Don’t use dual or single antiplatelet therapy in patients with _____

Answer 21

thromboembolic risk qualifying for OAC – HARM

Question 22

For the acute* management of stable AF:
Rate ____ Rhythm Control

Answer 22

>

Question 23

______: an acute rhythm control strategy, done
either electrically or pharmacologically

Answer 23

Cardioversion

Question 24

Atrial Fibrillation: Cardioversion goals in a stable patient

Answer 24

Rate control à Anticoagulation à Rhythm control
● If onset ≥48 hrs: OAC x 3 weeks and get echo before elective CV and
continue AC for 4 weeks afterward
● If onset < 48 hrs: start AC, consider echo if high risk score
● If duration <12 hrs: start AC, precardioversion echo low benefit
● If thrombus on echo, AC for 3-6 weeks, repeat echo and then CV

Question 25

Atrial Fibrillation: Cardioversion in unstable patient

Answer 25

Benefit of immediate cardioversion outweighs risk for thromboembolism
Rate control: 1 st line IV meds: BB or CCB
● Sedate
● Cardiovert à synchronous shock 100-200 J (on the R wave)
○ May repeat at 360 J
○ May need to load pt with anti-arrhythmic medications

Question 26

A more invasive strategy for rhythm control is
called ______ and can be used to scar portions of cardiac tissue believed to be the area(s) of active foci

Answer 26

Radiofrequency Catheter Ablation

Question 27

GOAL of subsequent management in A-fib patients:

Answer 27

maintaining normal sinus rhythm, reducing
thromboembolic events, and managing risk factors

Question 28

Antiarrhythmic medications

Answer 28

■ Sodium channel blockers (ie. Propafenone or Flecainide)
■ Potassium channel blockers (ie. Sotalol, Ibutilide, Amiodarone)

Question 29

What happens if A-fib is left untreated?

Answer 29

can result in permanent damage to the electrical conduction system and structure of the atria, and can also lead to heart failure.

Question 30

Atrial Flutter

Answer 30

● A-Flutter is another atrial arrhythmia,
similar to Atrial Fibrillation.
○ Like A-Fib, it’s commonly tachycardic. Unlike A-Fib, it’s characteristically regular on EKG.
● Much less common than A-Fib, incidence of 88 per 100,000 person- years, increases with age

Question 31

Atrial Flutter risk factors:

Answer 31

■ Any of the disorders that can cause A-Fib
■ Commonly occurs after starting an antiarrhythmic for suppression of A-Fib
(up to 15% of those on flecainide, propafenone, etc.)
■ Post Cardiac Surgery (can be early complication or late development)
■ Heart failure (16%)
■ COPD (12%)
■ Male sex (about 80% of A-Flutter patients are male)

Question 32

Typical Atrial Flutter

Answer 32

■ The more common of the two types, this is a
Macroreentrant Circuit within the right atrium
includes the Cavotricuspid Isthmus (CTI).
■ The circuit is generally counterclockwise and creates a classic sawtooth appearance best seen in the inferior leads (but can be reversed ↓).

Question 33

Atypical Atrial Flutter

Answer 33

■ The less common of the two types.
■ While it is also a macroreentrant circuit, it does not involve the CTI.
■ May form around a patch from a surgery or scar tissue (surgical or ablated)

Question 34

Atypical Atrial Flutter EKG findings

Answer 34

■ The appearance on EKG may not be quite as obviously A-Flutter as we see
with Typical type. May see sawtooth waves in only 1 or 2 leads

Question 35

Atrial Flutter S/S

Answer 35

■ Palpitations
■ Fatigue
■ Lightheadedness
■ Mild or (rarely) severe dyspnea
■ Hypotension
■ Anxiety
■ Presyncope and (infrequently) syncope
○ Because of the rapid atrial and (often) ventricular rates, several
hemodynamic changes can occur, which can result in decreased cardiac
output and blood pressure

Question 36

Atrial Flutter Treatment

Answer 36

○ Because ventricular rates can be sustained at around 150 bpm, rate control is an important component of treatment
○ Pharmacologic cardioversion to NSR is also difficult to achieve with most antiarrhythmics
○ Electrical cardioversion is a very effective treatment for about 90% of patients with A-Flutter, converting with shocks as low as 25-50 J.
○ Catheter Ablation of the CTI is a highly
successful treatment for Typical A-Flutter,

Question 37

Complications of atrial flutter

Answer 37

○ Serious complications include myocardial infarction, syncope, heart failure, and thromboembolism
○ Another complication of A-Flutter with RVR is tachycardia-induced cardiomyopathy, which can lead to chronic heart failure