Atrial fibrillation

Question 1

What are ECG changes in AF?

Answer 1

absent P waves
QRS < 120 ms
irregularly irregular rhythm
variable rate

Question 2

what are causes of AF?

Answer 2

sepsis
anaemia
thyroid dysfunction
ischaemic heart disease
rheumatic heart disease 
PE
COPD 
hypertension 
electrolyte disturbance 
alcohol 
increasing age

Question 3

what is 1st line medication for rate control in AF?

Answer 3

bisoprolol or verapamil

- Digoxin if heart failure

Question 4

what is 1st line medication for rhythm control in AF?

Answer 4

flecainide or amiodarone

Question 5

what are the different types of AF?

Answer 5

first detected episode
paroxysmal - 2 or more episodes that resolves spontaneously within 48hrs
persistent - 2 or more episodes which don’t spontaneously resolve
permanent - continuous AF which cannot be cardioverted or cardioversion is inappropriate

Question 6

what signs on examination would you find in AF?

Answer 6

irregularly irregular pulse

absent A wave in JVP

Question 7

how do you decide if you treat AF with rate control or rhythm control?

Answer 7

if onset of AF < 48 hours then either rate or rhythm control

if onset AF > 48 hours then rate control

Question 8

what factors favour rate control over rhythm control?

Answer 8

patient > 65yrs

ischaemic heart disease

Question 9

what factors favour rhythm control over rate control?

Answer 9

age < 65 yrs
alone AF or AF secondary to correctable precipitant e.g. alcohol
congestive heart failure

Question 10

describe the treatment of AF in patient who’s AF started > 48 hours ago.

Answer 10

rate control
- 1st line bisoprolol or verapamil or digoxin (if heart failure)

+ anticoagulants for 3 weeks

after 3 weeks - DC cardioversion

following cardioversion continue anticoagulants for 4 weeks

Question 11

if there was a high risk of cardioversion failure, what does NICE recommend?

Answer 11

give patient amiodarone or sotalol for 3 weeks prior to cardioversion

Question 12

describe the treatment for a patient who’s AF started < 48 hours ago.

Answer 12

rate or rhythm control (depending on patients age, first AF, lone AF, heart disease)

rate:
- 1st line - bisoprolol or verapamil or digoxin (if heart failure)

rhythm:
- heparin + DC cardioversion
- no anticoagulation required after cardioversion because it started < 48 hours ago

Question 13

when would you consider long term anticoagulants in a patient with AF?

Answer 13

consider in males if CHA2DS-VASc score 1 or more

offer to all if CHA2DS-VASc score 2 or more

Question 14

what medications are used to maintain sinus rhythm in patients with history of AF ?

Answer 14

flecainide
amiodarone
sotalol

Question 15

what treatment is considered for patients who have not responded to or wish to avoid antiarrythmic medication ?

Answer 15

catheter ablation
- radio frequency ablation or cryotherapy of the aberrant electrical activity between the pulmonary veins and left atrium

Question 16

what is the CHADSVAC2 score used for ?

Answer 16

to assess if a patient requires anticoagulation

Question 17

complications of catheter ablation ?

Answer 17

cardiac tamponade
stroke
pulmonary valve stenosis

Question 18

what anticoagulation is required for catheter ablation ?

Answer 18

patients require anticoagulation for 4 weeks before the procedure and during it.
further anticoagulation determined by CHADSVAC2 score
- if 0 = 2 months anticoagulation
- if >1 = lifelong anticoagulation

Question 19

features of CHA2DS2VASC score ?

Answer 19

congestive heart disease
hypertension 
age (>= 75 = 2 points, 65-74yrs = 1 point)
diabetes
stroke, TIA (2 points)
vascular disease 
sex (female)

score 1 in men = consider anticoagulation
score 2 = anticoagulation

Question 20

features of HASBLED score ?

Answer 20

hypertension, uncontrolled, systolic > 160mmHg
abnormal renal function (dialysis or creatinine > 200), abnormal liver function (cirrhosis, bilirubin 2x normal, AST/ALT/ALP 3x normal)
stroke history
bleeding history or tendency to bleed
labile INR (high, unstable, time in therapeutic range < 60%)
elderly > 65yrs
drugs i.e. NSAIDS, or alcohol abuse > 8 units/week

score 3 or above = high risk of bleeding

Question 21

post stroke, when is anticoagulation started and what is the anticoagulants of choice ?

Answer 21

2 weeks post stroke
direct thrombin inhibitor (dabigatran)
direct factor Xa inhibitor (apixiban/rivaroxiban)
warfarin