AF algorithm

Question 1

What defines unstable AF requiring urgent cardioversion?

Answer 1

shock, syncope, myocardial ischemia, or severe heart failure.

Question 2

What is the first-line intervention for unstable AF?

Answer 2

Immediate synchronized DC cardioversion (120–150 J biphasic) with sedation if conscious.

Question 3

What is the first-line pharmacological treatment for stable AF with no adverse features?

Answer 3

A: Rate control using beta-blockers (e.g., metoprolol, atenolol) or non-dihydropyridine calcium channel blockers (e.g., diltiazem, verapamil).

Question 4

When is rhythm control preferred in AF?

Answer 4

A: For recent-onset AF (< 48 hours) in symptomatic patients without structural heart disease.

Question 5

Rhythm control options

Answer 5

1. flecainide (if no heart failure/ischemia)
2. amiodarone.

Question 6

What anticoagulation is required before cardioversion for AF >48 hours?

Answer 6

A: Administer therapeutic anticoagulation (e.g., LMWH or DOAC) for ≥3 weeks pre-cardioversion or use transesophageal echocardiogram (TEE)-guided approach.

Question 7

How is thromboembolic risk assessed in AF?

Answer 7

CHA₂DS₂-VASc score:
- Male >1
- Female >2

Question 8

What drugs are contraindicated in AF with heart failure?
what to use instead?

Answer 8

Avoid verapamil, diltiazem, and flecainide.
- Use digoxin or amiodarone instead.

Question 9

What post-cardioversion monitoring is required?

Answer 9

• Continuous ECG
• anticoagulation for ≥4 weeks (unless CHA₂DS₂-VASc = 0)
• and treat underlying causes (e.g., hypertension, thyroid dysfunction).

Question 10

CHA₂DS₂-VASc score components

Answer 10

C = Congestive HF = 1
H = HTN = 1
A2 = Age >75 =2
D = DM = 1
S2 = stroke / TIA = 2
V = vascular disease IHD, PAD = 1
A = Age >65 =1
S = Female = 1

Question 11

Paroxysmal AF Mx

Answer 11

1. Flecanide (no struc/func heart disease)

Question 12

What defines paroxysmal AF according to NICE?

Answer 12

A: Episodes of AF that terminate spontaneously within 7 days of onset.

Question 13

What is the ‘pill-in-the-pocket’ strategy in paroxysmal AF?

Answer 13

A: Taking a single dose of an antiarrhythmic drug; flecainide at the onset of symptoms for infrequent, symptomatic episodes in suitable patients.

Question 14

What is the approach for patients with infrequent, brief, and minimally symptomatic paroxysmal AF episodes?

Answer 14

A: Consider no drug treatment or a ‘pill-in-the-pocket’ with Flecanide