Which drugs are used for rate control?
Beta blockers - Metoprolol, atenolol
Non-dihydropyridine calcium channel blockers
Which drugs are used for rhythm control in AF?
What is an important side effect of sotalol?
Prolonged QT interval
When is flecainide contraindicated?
In IHD and structural heart disease due to risk of arhythmias
What is the mechanism of action of amiodarone?
Na+ and Ca+ blocker
Increases the refractory period
What are some side effects of amiodarone?
Liver - elevated LFTs
Lung - pulmonary fibrosis
Skin - Blue/gray discolouration
Eye - Corneal microdeposits
Hyper or hypo thyroidism
What are some non-pharmacological interventions for rhythm control?
Pulmonary vein catheter ablation
What are the novel oral anticoagulants?
What are the "three P's" that are used to describe the different natural histories of AF?
Paroxysmal - Abrupt onset, revert spontaneously within 24-48 hours
Persistent - Abrupt onset, can persist for weeks to months if definitive intervention isn't undertaken
Permanent - Refractive to treatment
Which drugs should be avoided if AF is coexistent with HF?
What is optimal, rate or rhythm control (and anticoagulation for both) in patients with chronic or persistent AF?
There is no morbidity or mortality benefit for one over the other
(2002, AFFIRM trial)
What are the principles of management of a patient with new onset paroxysmal AF (<48)?
- Reversion to sinus rhythm is preferred
- Anti-coagulation is added while this is done to prevent thrombus formation
- Flecainide (2mg/Kg IV over 30mins) or amiodarone (5mg/kg over 20mins)
- Electrical cardioversion is performed if spontaneous or pharmacological reversion fails
What are the principles of management of a patient with rapid AF of >48 hours duration?
- Risk of thromboembolism is significant therefore rate control is prefered to reversion in the acute setting (unless the symptoms are severe)
- Oral metoprolol, diltiazem, or verapamil if not severe
- IV metoprolol, verapamil, or esmolol +/- MgSO4 if more unstable
What is the best option for treatment of new AF in the setting of WPW?
Flecainide or Amiodarone are the prefered drugs
What are the three "S's" of approaching a patient in AF?
How do you approach the Ix and management of AF?
- 12 lead ECG
- UEC, CMP
- Rate vs Rhythm control
- Targets K > 4, Mg > 1
- Ix for cause
How do you dose therapeutic clexane? How long do you place a bridging dose for?
1mg/kg bd, adjusted for renal function
What is the normal target INR? What about for mechanical valves?
Outline the CHA2DS2VASc score
C - CCF
H - HTN
A - Age >75 = 2 points
D - DM
S - Stroke/TIA Hx = 2 points
V = Vascular disease
A = Age 65-74
Sc = Sex, female = 1