AF & Hypertension

Question 1

What type of AF is more common in younger patients?

Answer 1

Paroxysmal

Question 2

How would you describe AF to a patient?

Answer 2

AF is an abnormally fast and irregular heart rhythm meaning that you heart cannot fill with blood as effectively and can’t pump blood as effectively around your body
Symptoms include palpitations, dizziness, shortness of breath & tiredness

Question 3

What is the average atrial rhythm in AF and average ventricular rhythm?

Answer 3

Atrial: 300-600 bpm
Ventricular: 160-180

Question 4

What are the most common causes of AF?

Answer 4

Ischaemic heart disease/ heart failure 
MI
Htn 
Valvular heart disease
Hyperthyroid

Question 5

What are some less common causes of AF?

Answer 5

Caffeine/ alcohol 
PE
pneumonia 
post-op 
Hypokalaemia/ hypomagnaesia

Question 6

What is paroxysmal AF?

Answer 6

Episodes lasting >30 seconds but less than 7 days
Self limiting & recurrent
More common in younger

Question 7

What is persistent AF?

Answer 7

2 or more episodes
Require medical/DC cardioversion to resolve
Return

Question 8

What is permanent AF?

Answer 8

AF not resolved with cardioversion
AF that relapses within 24 hours
Controlled by rate limiting drugs

Question 9

What are the complications of AF?

Answer 9

Stroke/TIA - thromboembolic risks or anticoagulant risk due to warfarin
Heart failure

Question 10

How would AF be described on an ECG?

Answer 10

Irregularly irregular narrow complex tachycardia

Absent P waves

Question 11

What investigations are carried out if suspected AF?

Answer 11

24 hour ambulatory ECG

Question 12

What would be seen on an ECHO in AF?

Answer 12

(Left) atrial enlargement

mitral valve disease

Question 13

What is CHADS2VASC score used to determine?

What are the components?

Answer 13

Assess stroke risk
C - congestive HF = 1
H - hypertension - 1
A - age ≥75 = 2
D - diabetes = 1
S2 - stroke/TIA/ thromboembolism = 2
V - vascular disease = 1
A - age 65-74 = 1
S - sex female = 1

Question 14

What is the recommendation of a Female with a chads2vasc score of 1?

Answer 14

No action - she is scoring for sex

Question 15

What is the recommendation of a male with a chads2vasc score of 1?

Answer 15

Consider starting anticoagulation

Question 16

What is the recommendation of a Female with a chads2vasc score of 2?

Answer 16

Offer anticoagulation

Question 17

What anticoagulation is recommended for AF?

Answer 17

Warfarin

NOAC

Question 18

What is the risk of a person with AF developing a stroke compared to someone in normal sinus rhythm?

Answer 18

5x higher

Question 19

What tool is used to assess someone’s bleeding risk with anticoagulant?

Answer 19

HAS BLED

H - hypertension = 1
A - abnormal renal/liver function = 1 or 2
S - stroke = 1

B - bleeding = 1
L - labile INRs = 1
E - elderly >65 = 1
D - drugs/alcohol = 1 or 2

Question 20

What is the normal starting dose of warfarin?

Answer 20

5-10mg

Question 21

What is the target INR for those with AF?

Answer 21

2-3

Question 22

Who should warfarin be avoided in?

Answer 22

Pregnancy - teratogen
Peptic ulcer
Bleeding disorders
p450 metabolising drugs

Question 23

What is the mechanism of action of warfarin?

Answer 23

Vitamin K antagonist

Question 24

What is the mechanism of action of NOACs?

Answer 24

Inhibit free factor Xa

Question 25

What is the dose of NOACs?

Answer 25

20mg OD with food

Question 26

What is first line for rate control in AF? | When is this contraindicated?

Answer 26

B-blocker - metaprolol Use rate limiting CCB if asthmatic - verapamil/diltiazem If not controlled then combine b blocker & diltiazem or digoxin DO NOT COMBINE B-BLOCKER AND VERAPAMIL = COMPLETE HEART BLOCK

Question 27

When is digoxin used in rate control of AF?

Answer 27

Not as effective as CCB or B-blocker Used in HF

Question 28

What is used to maintain sinus rhythm in those with known AF?

Answer 28

Sotalol Amiodarone Flecainide

Question 29

If a haemodynamically stable patient presents with AF 12 hours after onset what is the treatment?

Answer 29

Pharmacological cardioversion - flecainide or amiodarone

Question 30

What is the treatment for all new onset AF?

Answer 30

LMWH - tinzaparin until assessment is made

Question 31

What is classified as hypertension?

Answer 31

BP > 140/90

Question 32

What is classified as malignant hypertension?

Answer 32

>200/120

Question 33

What should BP aim be for those age ≥80?

Answer 33

150/90

Question 34

Further testing should not be conducted and treatment started right away if the BP is what?

Answer 34

>180/90

Question 35

Ambulatory BPM takes the average of at least how many BP readings throughout the day?

Answer 35

14

Question 36

ABPM of what indicates need for treatment?

Answer 36

``` <80 = 135/85 >80 = 145/85 ```

Question 37

What is used to assess cardiovascular risk? What does it calculate? How often should this be repeated?

Answer 37

QRISK2 % risk of MI or stroke in next 10 years Repeat every 5 years

Question 38

What other investigations should be done when suspecting htn?

Answer 38

U&Es - inc. createnine Glucose - DM or obese eGFR

Question 39

For someone with stage 1 htn, medication is started when the QRISK2 score is?

Answer 39

>20%

Question 40

What is 2nd line management of htn if 1st line is not adequate?

Answer 40

ACE-i + CCB OR ARB

Question 41

What is 3rd line management of htn?

Answer 41

ACE-i + CCB + Thiazide (ACD)

Question 42

What is 4th line management of htn?

Answer 42

``` Add alpha-blocker OR Add another diuretic - low dose k+ sparing or high dose thiazide OR Beta-blocker ```

Question 43

ARB should be preferred over ACE-i in which group of people?

Answer 43

Afro-carribean

Question 44

Why should you try not to combine ACE-i with ARB or B-blocker with diuretic?

Answer 44

can aggravate diabetes

Question 45

What is 2nd line treatment of htn in afro-carribeans?

Answer 45

CCB + ARB ARB preferred over ACE-i