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AF Flashcards

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1
Q

Why is AF important? What does it cause?

A

Irregular cardiac rhythm associated with AF decreases the heart’s ability to efficiently pump blood and promotes clot formation

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2
Q

People with AF have a higher risk of what?

A

Stroke
HF
MI
Dementia
Mortality

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3
Q

Does successful treatment reverse the risks associated with AF?

A

Successful treatment doesn’t completely reverse the increased risks associated with AF

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4
Q

Typical presentation (symptoms) of patients with AF

A

Often asymptomatic
If symptomatic symptoms can vary (palpitations, dizziness, SOB esp on exertion, angina, fatigue)

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5
Q

Who should you opportunistically screen for AF by feeling radial pulse?

A

≥ 65 yo (or younger if Maori/Pacific, previous TIA, HTN)

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6
Q

If AF is suspected on pulse what should you do?

A

Confirm with ECG

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7
Q

AF features on ECG

A

Irregularly irregular RR interval
No discernible distinct P waves

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8
Q

When might you request a Holter monitor for suspected AF?

A

If patient reports intermittent palpitations (i.e. paroxysmal AF suspected)

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9
Q

Role of smart watches in detecting AF

A

Positive predictive values for AF 84 – 98% → clinically significant but does not replace need for clinical assessment (pulse, ECG, holter if needed)

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10
Q

Underlying causes of AF include…

A

Infection
Dehydration
Surgery – cardiac or other major surgery
Cardiac (MI, hypertensive or valvular heart disease, cardiomyopathy, inherited conditions)
Respiratory, e.g. acute exacerbation of COPD, OSA, PE, pneumonia
Excessive alcohol intake
Thyrotoxicosis
Obesity

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11
Q

Bloods to order in work up for AF

A

CBC, UEC
LFTs and TFTs if not recently done
INR and APTT if starting oral anticoagulants

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12
Q

Investigations to request once AF confirmed on ECG

A

Echo

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13
Q

Classification of AF includes…

A

First diagnosed
Paroxysmal
Persistent
Long-standing persistent
Permanent

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14
Q

Definition of first diagnosed AF

A

AF not been diagnosed before, irrespective of sx presence/severity

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15
Q

Definition of paroxysmal AF

A

AF that resolves spontaneously or is cardioverted within 7 days

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16
Q

Definition of persistent AF

A

Continuous AF for >7 days that has not resolved spontaneously
Includes episodes that are cardioverted ≥7 days

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17
Q

Definition of long-standing persistent AF

A

AF has lasted continuously for ≥1 year and attempts to restore or maintain sinus rhythm are still being considered or attempted

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18
Q

Definition permanent AF

A

AF present for ≥1 year and cardioversion has been unsuccessful or not attempted

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19
Q

Who to refer to acutely to secondary care when presenting with AF

A

Onset AF definitely <12hrs
Haemodynamically unstable (hypotension, peripheral cyanosis, ongoing chest pain)

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20
Q

How do you determine decisions around anticoagulation with AF

A

Assess CHA2DS2-VASc score (stroke risk) and HAS-BLED score (bleeding risk)

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21
Q

Stroke risk between different types of AF

A

Stroke risk same regardless of underlying pattern & whether symptomatic or not

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22
Q

Consider anticoagulation if CHA2DS2-VASc is…

A

≥ 2 in females
≥ 1 in males

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23
Q

What CHA2DS2-VASc score indicates low risk of stroke (<1:100 per year) and therefore anticoagulation not generally considered

A

1 females
0 males

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24
Q

For patients with low stroke risk (low CHA2DS2-VASc scores) should you consider antiplatelets?

A

Antiplatelet not recommended as an alternative to anticoagulation

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25
Need for anticoag primarily based on CHA2DS2-VASc or HAS-BLED?
CHA2DS2-VASc
26
What is HAS-BLED useful for?
Balance benefits and risks of anticoag e.g. high HAS-BLED, low CHA2DS2-VASC (≤ 2) risk may outweigh benefits Identify factors to reduce bleeding risk (e.g. uncontrolled HTN, NSAID use, alcohol excess) Identify pts at higher risk who could benefit from more frequent f/up
27
Are there specific cut offs with HAS-BLED score for not starting anticoag?
No Consequences of stroke usually more severe than consequences of bleed
28
What is first line treatment for stroke prevention in patients with AF
Oral anticoagulants - warfarin, dabigatran or rivaroxaban
29
Absolute contraindications for oral anticoagulation
Active serious bleeding Bleeding-associated co-morbidities, e.g. severe thrombocytopenia (< 50 platelets/microlitre) or severe anaemia History of recent high-risk bleeding event, e.g. intracranial haemorrhage
30
Why are DOACs preferred over warfarin?
Superior for reducing stroke risk and all-cause mortality Reduce risk of intracranial bleeding Comparable risk of major bleeding No INR monitoring required Fewer medicine and food interactions More rapid onset of action
31
Pros/cons of dabigatran and rivaroxaban
Dabigatran twice daily dosing, rivaroxaban once daily Rivaroxaban can use to CrCl 15, dabigatran to CrCl 30
32
Dosing of dabigatran
150mg BD if CrCl >50 110mg BD if ≥ 80yo, 75-80yo with low clot risk and high bleeding risk, CrCl 30-49
33
Dosing of rivaroxaban
20mg once daily if CrCl >50 15mg once daily if CrCl 15-49
34
When to consider warfarin?
DOACs C/I Significant hx of GI disease Comorbid antiphospholipid syndrome (rare) Patients who develop thrombosis while taking a DOAC
35
Contraindications for DOACs
Mechanical heart valve or insufficient evidence to support their use (e.g. mod-severe mitral stenosis, severe liver or renal dysfunction)
36
Anticoagulation in pregnancy
Refer O&G Enoxaparin usually safest (doesn’t cross placenta or cause fetal anticoagulation)
37
Can you use antiplatelets for stroke prevention in AF
Long term antiplatelet use alone not recommended in patients with AF
38
Anticoags + antiplatelets in AF
After ACS or coronary stent patients can be on clopidogrel as well DAPT + anticoag not recommended
39
Should you stop anticoags if concerns re age or falls risk in a patient with high stroke risk?
No - Benefits usually outweigh risk of complications
40
Should you stop anticoag if a patient reverts to sinus rhythm or is asymptomatic?
No
41
Stopping anticoag should be based on...
Stroke and bleeding risk (CHA2DS2-VASc and HAS-BLED scores)
42
What is rate control
Aims to improve sx by reducing HR
43
What is rhythm control
Attempts to restore sinus rhythm either by electrical cardioversion or pharmacological cardioversion with antiarrhythmic medicines
44
What is more effective - rate or rhythm control?
RCT suggests both strategies have similar effect on QoL and clinical outcomes (incl mortality)
45
Should you start rate or rhythm control in primary care?
Start with rate control (simpler regimes, fewer S/E)
46
Rhythm control may be started first with cardio advice in certain patients including...
Younger, esp if very physically active and no co-morbidities High initial symptom burden Symptomatic paroxysmal attacks Clear trigger or reversible cause for AF e.g. recent cardiac surgery, acute illness, binge drinking HF primarily caused or exacerbated by AF
47
What reduces probability of successful rhythm control
Longer duration of persistent AF
48
1st line rate control
BB, rate limiting CCB (e.g. diltiazem, verapamil)
49
Can you use sotalol as rate control?
Not recommended - potential to cause arrhythmias
50
How do you choose between BB and CCB for rate control?
Based on echo results (LVEF)
51
If no echo then it is safest to start ___________ for rate control
Beta blocker Verapamil and diltiazem not recommended if LVEF <40% or HFrEF due to negative inotropic effects
52
Why is diltiazem not usually used as monotherapy
Potential for medicine interactions Lack of effect on HR during physical activity Narrow therapeutic index
53
First line monotherapy for rate control if LVEF ≥ 40%
Beta blocker - bisoprolol, metoprolol succinate, carvedilol Rate limiting CCB - verapamil, diltiazem Digoxin
54
Dose of bisoprolol for rate control
1.25 – 20 mg, once daily (usual range 2.5 mg – 10 mg)
55
Dose of metoprolol for rate control
23.75 – 190 mg, once daily
56
Dose of carvedilol for rate control
3.125-50 mg BD
57
Dose of diltiazem for rate control
60 mg TDS, increased to 360 mg max total daily dose in divided doses (IR form) or 120 – 360 mg, once daily (MR form)
58
Dose of verapamil for rate control
40-120 mg TDS (IR form) or 120-240 mg, once daily, increased to 240 mg BD if necessary (MR form)
59
Dose of digoxin for rate control
0.75-1.5 mg, over 24 hours in divided doses (loading dose) then 0.0625-0.25 mg, once daily (maintenance dose)
60
Combination treatment for rate control with BB and CCB for LVEF ≥ 40%
Add digoxin to either the BB or rate-limiting CCB Combine a BB with diltiazem (i.e. without digoxin)
61
Do not use ___________ with a BB due to the risk of hypotension and systole as a result of the potentially additive negative inotropic effects.
Verapamil
62
First line rate control if signs of CHF and LVEF < 40%
BB (1st line) Digoxin
63
Combination treatment for rate control with BB and digoxin when signs of CHF and LVEF < 40%
BB - add digoxin Digoxin - add BB at lowest possible dose for acute HR control
64
Treatment targets - HR
Most patients aim resting HR <110 More intensive if ongoing symptoms or LV dysfunction e.g. HR 80-90
65
How to titrate medication for rate control
Start low dose and f/up 1-2 weeks for titration Consider combination treatment if HR target not achieved with optimal monotherapy
66
What should you do if sustained increase in HR despite previous adequate control
Assess for temporary/modifiable causes before increasing treatment e.g. post-op stress, changes in alcohol consumption. Consider ECG ?atrial flutter (may require different Rx approach)
67
Options for pharmacological cardioversion for rhythm
Amiodarone Flecainide Sotalol
68
What should you do if pharmacological cardioversion fails
Refer for consideration of electrical cardioversion, catheter or surgical ablation
69
Antiarrhythmic meds usually continued for _________ post ablation to limit recurrence
≥ 3 months
70
Modifiable risk factors for AF
HTN Obesity Sedentary lifestyle Diabetes OSA Alcohol Smoking
71
Is caffeine a risk factor for AF
No evidence that caffeine is a significant risk factor for AF (but can trial reduction if triggers/worsens sx)
72
Is vigorous exercise a risk factor for AF
Increasing evidence of an association between prolonged vigorous exercise (e.g. endurance exercise) and increased AF risk. Risk highest in middle age
73
F/up if patient is on a DOAC
UEC every 6 – 12 months if normal at baseline; more frequent if baseline CrCl is reduced. Baseline liver dysfunction may also need regular LFTs (can influence DOAC clearance → increasing the degree and/or duration of anticoagulation
74
When to refer to cardiology
Ongoing sx and poorly controlled HR e.g. >110 despite appropriate pharmacological Rx Recurrence of AF after cardioversion Paroxysmal AF with ongoing sx (for consideration of ablation or other advanced Rx) An elevated stroke risk but long-term oral anticoagulation is contraindicated Symptomatic bradycardia with no improvement after reducing or withdrawing rate control Other signs of deteriorating cardiac health, e.g. HF, esp if reduced LVEF on echo
75

GPEP cardio (3 decks)

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