AF

Question 1

definition

Answer 1

Irregular atrial contraction caused by chaotic impulses

Classically caused by multiple waves of electrical impulses leading to fragmentation of the normal coordinated electrical activity in the atria causing independent contraction leading to fibrillation

Question 2

characteristics on a ECG

Answer 2

• Irregularly irregular rhythm
• Absent P waves - no coordination in atrial activity
• Irregular fibrillating baseline

Question 3

Epidemiology

Answer 3

Most common sustained cardiac arrhythmia 

Question 4

Aetiology

Answer 4

Mrs SMITH
- Sepsis
- Mitral valve pathology - stenosis or regurgitation
- Ischaemic heart disease
- Thyrotoxicosis
- Hypertension

Question 5

Aetiology cardiac

Answer 5

Hypertension
Ischaemic heart disease
Valvular heart disease
Myocardial infarction
Cardiomyopathy

Question 6

aetiology Non cardiac

Answer 6

Respiratory
COPD, pneumonia, PE
Endocrine
Hyperthyroidism (everything goes faster), diabetes mellitus
Acute infections
Electrolyte imbalances
Hypokalaemia, hypomagnesaemia, hyponatraemia
Drugs
Bronco dilators, thyroxine
Lifestyle factors
Alcohol, excessive caffeine, obesity

Question 7

signs

Answer 7

Irregularly irregular pulse
Absent ‘a’ wave on JVP: corresponds to atrial contraction
Tachycardia
Hypotension
Features of heart failure: bibasal crackles, raised JVP, peripheral oedema

Question 8

Symptoms

Answer 8

Palpitations (heart beating out of chest)
Chest pain
SOB
Dizziness (as inadequate blood reaching the brain)

Question 9

gold standard

Answer 9

Gold standard:
Ambulatory ECG monitoring - able to pick up paroxysmal episodes that wouldn’t be seen on a 12 lead
24 hour
48 hour
7 day
Loop recorder - 3 years

Question 10

other tests

Answer 10

bloods
echo

Question 11

Causes of irregularly irregular pulses

Answer 11

Premature beats - ectopic
Atrial flutter with variable block
Other atrial tachyarrhythmias

Question 12

reasons of management

Answer 12

rate controll, rhythm controll, prevention

Question 13

Rate control - first line strategy

Answer 13

• BB first line (not in asthma or hypoT)
• CCB - diliazem, verapamil (not in HF)
• digoxin - needs monitoring, risk of toxicity, only for those who are sedentary

Question 14

Rhythm control

Answer 14

• Amiodarone - drug for patients with structural heart disease
• Flecainide - used In paroxysmal AF
• Beta blockers

DC cardioversion
- immediate - If the AF has been present for less than 48 hours or they are severely haemodynamically unstable
- delayed cardioversion - If the AF has been present for more than 48 hours and they are stable
Patient should be anti-coagulated for minimum of 3 weeks prior

catheter ablation
- new
- essentially damages atria tissue to prevent electrical transmission

Question 15

Prevention of thromboembolic events

Answer 15

first line - DOACS:
Apixaban
Rivaroxaban

warfarin - valvae AF

LMWH - patients who cant tolerate it orally

Question 16

CHA2DS2-VASc

Answer 16

assess risk of stroke

DOACs are offered as first line
Warfarin is used if DOACs are not suitable

Scores of 2 and above are recommended anticoagulation

Question 17

ORBIT

Answer 17

Risk tool looking to identify patients at risk of a major bleeding event on anticoagulation

Score of:
4-7 = -3 high risk
3 = medium risk
0-2 = -2 low risk

Question 18

cardiac complications

Answer 18

Heart failure
Tachycardia-induced cardiomyopathy
Ischaemia
Sudden cardiac arrest

Question 19

non-cardiac complications

Answer 19

Thromboembolic events: stroke, TIA, mesenteric ischaemia, ischaemic limb
Collapse
Bleeding events (anticoagulation)

Question 20

presented with AF >48 hours getting cardioversion

Answer 20

should be anticoagulated for 3 weeks before using eg apixoban

Question 21

mitral stenosis

Answer 21

Rheumatic fever 95% of cases
AF common association
diastolic
apex tap

Question 22

at what point do you prescribe rate control

Answer 22

HR 90+

Question 23

when can you do cardioversion

Answer 23

only <48hrs or you anticoag for 3 weeks before and 2 weeks after

Question 24

what CHA2D score requires anticoag

Answer 24

female - 2
male - 1

Question 25

if patient comes in high HR low BP

Answer 25

electrocardioversion

Question 26

seemingly most common non-cardiac cause of AF

Answer 26

alcohol

Question 27

pill in pocket drug

Answer 27

Flecainide

Question 27

why does an apical to radial pulse defect occur

Answer 27

not all atrial impulses (palpable at the apex) are mechanically conducted to the ventricles (palpable as a peripheral pulse)

Question 28

CHA2D score of 0 but valvar condition

Answer 28

still anticoag all patients with valve condition should be anticoagulated

Question 29

acute / new onset management <48hrs

Answer 29

- fleicanide - no structural defects - amiodarone - structural defects electrical cardioversion with 4 weeks of anticoag after

Question 30

new onset stable onset >48 hours

Answer 30

rate control only rate control with BB, dilitazem or digoxin

Question 31

chronic AF management

Answer 31

1st line: BB - bisoprolol CCB - diliazem 2nd line: dual therapy digoxin - non-paryoxsmal

Question 32

when is rhythm control given in chronic cases

Answer 32

- AF secondary to reversable cause - heart failure caused by AF - new onset AF must have - <48hrs - 3 weeks anticoag - TOE to exclude thrombus

Question 33

rhythm control drugs and when each is used

Answer 33

flecainide: - pill in pocket - young people - structurally normal heart amiadrone: - rate and rhythm - lots of side effects - older sedatory patients satolol: - last resort - BB + K channel blocker

Question 34

antiCoag in AF

Answer 34

DOAC - first line suffix aban warfarin - for valavr AF LMWH - patient who cant tolerate it orally