ATRIAL FIBRILLATION/ATRIAL FLUTTER

Question 1

Atrial Fibrillation definition

Answer 1

Characterised by rapid, chaotic and ineffective atrial electrical conduction.

Question 2

Explain the aetiology and risk factors of atrial fibrillation

Answer 2

• Systemic Causes 
  o  Thyrotoxicosis  
  o  Hypertension  
  o  Pneumonia 
  o  Alcohol 
•  Heart Causes 
  o  Mitral valve disease  
  o  Ischaemic heart disease   
  o  Rheumatic heart disease   
  o  Cardiomyopathy 
  o  Pericarditis 
  o  Sick sinus syndrome 
  o  Atrial myxoma 
•  Lung Causes 
  o  Bronchial carcinoma 
  o  PE

Question 3

Summarise the epidemiology of atrial fibrillation

Answer 3

• VERY COMMON in the elderly
• Present in 5% of those > 65 years
• May be paroxysmal

Question 4

Recognise the presenting symptoms of atrial fibrillation

Answer 4

• Often ASYMPTOMATIC
• Palpitations
• Syncope (if low output)
• Symptoms of the cause of AF

Question 5

Recognise the signs of atrial fibrillation on physical examination

Answer 5

• Irregularly irregular pulse
• Difference in apical beat and radial pulse
• Check for signs of thyroid disease and valvular disease

Question 6

Identify appropriate investigations for atrial fibrillation

Answer 6

• ECG

•  Bloods 
Cardiac enzymes  
TFT 
Lipid profile  
U&Es, Mg2+ and Ca2+ 

•  Echocardiogram  
Mitral valve disease  
Left atrial dilatation 
Left ventricular dysfunction   
Structural abnormalities

Question 7

What will an ECG of AF show

Answer 7

o Uneven baseline
o with absent p waves
o Irregular intervals between QRS complexes

o Atrial flutter = sawtooth

Question 8

What are the two components of the management plan for AF

Answer 8

rhythm and rate control

Question 9

Generate a management plan for atrial fibrillation

Answer 9

• RHYTHM CONTROL
o If > 48 hrs since onset of AF
• Anticoagulate for 3M4 weeks before attempting cardioversion
o If < 48 hrs since onset of AF
• DC cardioversion (2 x 100 J, 1 x 200 J)
• Chemical cardioversion: flecainide or amiodarone
! NOTE: flecainide is contraindicated if there is a history of ischaemic heart disease
o Prophylaxis against AF
• Sotalol
• Amiodarone
• Flecainide
• Consider pillMinMtheMpocket (single dose of a cardioverting drug (e.g.
flecainide) for patients with paroxysmal AF) strategy for suitable patients

•  RATE CONTROL 
o  Chronic (Permanent) AF 
•  Control ventricular rate with: 
!  Digoxin  
!  Verapamil 
!  BetaMblockers 
•  Aim for ventricular rate ~ 90 bpm

Question 10

Identify the possible complications of atrial fibrillation

Answer 10

• THROMBOEMBOLISM
o Embolic stroke risk of 4% per year
o Risk is increased with left atrial enlargement or left ventricular dysfunction
• Worsening of existing heart failure

Question 11

Summarise the prognosis for patients with atrial fibrillation

Answer 11

Chronic AF in a disease heart does not usually return to sinus rhythm

Question 12

Atrial Fibrillation 3 divisions

Answer 12

Often subdivided into:
o Permanent
o Persistent
o Paroxysmal