AF

Question 1

4 causes

Answer 1

IHD

HTN

Valve disease

Hyperthyroid

Question 2

3 complications

Answer 2

Stroke/thromboembolism

HF

Tachycardia induced cardiomyopathy and critical cardiac ischaemia

Question 3

What is the HR of AF often?

Answer 3

160-180BPM

Question 4

AF on ECG?

Answer 4

No p waves, irregular ventricular rate, chaotic baseline

Question 5

Presentation AF

Answer 5

Breathlessness

Palps

Chest discomfort

Syncope/dizziness

Low exercise tolerance, malaise

Polyuria

A complication e.g. stroke, tia

Question 6

What is paroxysmal AF?

Answer 6

Episodic and less than 48hrs

Question 7

What could paroxysmal AF be triggered by

Answer 7

caffeine, alcohol

Question 8

Investigations

Answer 8

Pulse and ECG

Question 9

Is pulse palpation sensitive and specific?

Answer 9

Sensitive but not that specific

Question 10

Irregular pulse indicates what is needed?

Answer 10

ECG

Question 11

Paroxysmal AF susp needs what investigation

Answer 11

Ambulatory ECG

Question 12

Differentials

Answer 12

Atrial flutter

Atrial extrasystoles

Ventricular ectopics

Sinus tachycardia (>100BMP)

SVTs

Multifocal atrial tachycardia

Question 13

Management

Answer 13

(admit if complications)

1. Rate control- beta blocker or CCB
2. Rhythm control in some cases (referral)- electrical or pharmacological (amiodarone, sotalol)
3. CHADVASC stroke risk
4. Anti-coag- use HASBLED to assess bleed risk. Warfarin or NOAC
5. f/u for rate control (effectiveness and tolerability) and anticoag (compliance and SEs)

Identify and manage cause

Question 14

How do you know whether to give BB or CCB?

Answer 14

Depends on co-morbs- no BB in asthma, no CCB in HF

Question 15

4 categories AF

Answer 15

first detected episode

paroxysmal

persistent

permanent.

Question 16

What is permanent AF?

Answer 16

cannot be cardioverted or if attempts to do so are deemed inappropriate. Treatment goals are therefore rate control and anticoagulation if appropriate

Question 17

What is recurrent AF?

Answer 17

> 2 episodes. This is either persistent or paroxysmal.

Paroxysmal terminates spontaneously (<7 days, usually <24h)

Persistent not self terminating, usually >7days

Question 18

What are the two key management goals of AF?

Answer 18

1. Rate/rhythm control

2. Reducing stroke risk

Question 19

Do patients always need to be converted back to sinus rhythm?

Answer 19

No, often leave them. Only if e.g. coexistent heart failure, first onset AF or where there is an obvious reversible cause.

Question 20

What if rate isn’t adequately controlled on one drug?

Answer 20

Use two of these in any combination:

a betablocker

diltiazem

digoxin

Question 21

What is a risk with cardioversion? How is this mitigated?

Answer 21

the moment a patient switches from AF to sinus rhythm presents the highest risk for embolism leading to stroke.

For this reason patients must either have had a short duration of symptoms (less than 48 hours) or be anticoagulated for a period of time prior to attempting cardioversion.

Question 22

What does CHADVASC stand for?

Answer 22

Congestive HF

HTN (incl treated)

Age

DM

Prior stroke or TIA (2)

Vascular disease

Sex female

Question 23

What should your action be based on the CHADVASC?

Answer 23

Offer anticoag (NOAC or warfarin) if >2, and if >1 in men

Question 24

How could you investigate underlying cause?

Answer 24

Review ECG (prev MI)

Bloods- TFT, FBC, U+E, calcium, Mg, glucose

Transthoracic echocardiogram (if susp underlying cardiac disease)

CXR if lung pathology susp

Question 25

Management acute AF

Answer 25

1. emergency electrical cardioversion
2. a) Heparin at presentation if new onset and no anticoag therapy atm
   b) oral anticoags IF sinus rythm not restored within 48hrs OR high risk recurrence OR risk stroke

Question 26

90% AF is due to?

Answer 26

Organic heart disease