What type of AF is more common in younger patients?
Paroxysmal
How would you describe AF to a patient?
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
What is the average atrial rhythm in AF and average ventricular rhythm?
Atrial: 300-600 bpm
Ventricular: 160-180
What are the most common causes of AF?
Ischaemic heart disease/ heart failure MI Htn Valvular heart disease Hyperthyroid
What are some less common causes of AF?
Caffeine/ alcohol PE pneumonia post-op Hypokalaemia/ hypomagnaesia
What is paroxysmal AF?
Episodes lasting >30 seconds but less than 7 days
Self limiting & recurrent
More common in younger
What is persistent AF?
2 or more episodes
Require medical/DC cardioversion to resolve
Return
What is permanent AF?
AF not resolved with cardioversion
AF that relapses within 24 hours
Controlled by rate limiting drugs
What are the complications of AF?
Stroke/TIA - thromboembolic risks or anticoagulant risk due to warfarin
Heart failure
How would AF be described on an ECG?
Irregularly irregular narrow complex tachycardia
Absent P waves
What investigations are carried out if suspected AF?
24 hour ambulatory ECG
What would be seen on an ECHO in AF?
(Left) atrial enlargement
mitral valve disease
What is CHADS2VASC score used to determine?
What are the components?
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
What is the recommendation of a Female with a chads2vasc score of 1?
No action - she is scoring for sex
What is the recommendation of a male with a chads2vasc score of 1?
Consider starting anticoagulation
What is the recommendation of a Female with a chads2vasc score of 2?
Offer anticoagulation
What anticoagulation is recommended for AF?
Warfarin
NOAC
What is the risk of a person with AF developing a stroke compared to someone in normal sinus rhythm?
5x higher
What tool is used to assess someone’s bleeding risk with anticoagulant?
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
What is the normal starting dose of warfarin?
5-10mg
What is the target INR for those with AF?
2-3
Who should warfarin be avoided in?
Pregnancy - teratogen
Peptic ulcer
Bleeding disorders
p450 metabolising drugs
What is the mechanism of action of warfarin?
Vitamin K antagonist
What is the mechanism of action of NOACs?
Inhibit free factor Xa
What is the dose of NOACs?
20mg OD with food
What is first line for rate control in AF?
When is this contraindicated?
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
When is digoxin used in rate control of AF?
Not as effective as CCB or B-blocker
Used in HF
What is used to maintain sinus rhythm in those with known AF?
Sotalol
Amiodarone
Flecainide
If a haemodynamically stable patient presents with AF 12 hours after onset what is the treatment?
Pharmacological cardioversion - flecainide or amiodarone
What is the treatment for all new onset AF?
LMWH - tinzaparin until assessment is made
What is classified as hypertension?
BP > 140/90
What is classified as malignant hypertension?
> 200/120
What should BP aim be for those age ≥80?
150/90
Further testing should not be conducted and treatment started right away if the BP is what?
> 180/90
Ambulatory BPM takes the average of at least how many BP readings throughout the day?
14
ABPM of what indicates need for treatment?
<80 = 135/85 >80 = 145/85
What is used to assess cardiovascular risk?
What does it calculate?
How often should this be repeated?
QRISK2
% risk of MI or stroke in next 10 years
Repeat every 5 years
What other investigations should be done when suspecting htn?
U&Es - inc. createnine
Glucose - DM or obese
eGFR
For someone with stage 1 htn, medication is started when the QRISK2 score is?
> 20%
What is 2nd line management of htn if 1st line is not adequate?
ACE-i + CCB OR ARB
What is 3rd line management of htn?
ACE-i + CCB + Thiazide (ACD)
What is 4th line management of htn?
Add alpha-blocker OR Add another diuretic - low dose k+ sparing or high dose thiazide OR Beta-blocker
ARB should be preferred over ACE-i in which group of people?
Afro-carribean
Why should you try not to combine ACE-i with ARB or B-blocker with diuretic?
can aggravate diabetes
What is 2nd line treatment of htn in afro-carribeans?
CCB + ARB
ARB preferred over ACE-i
