AFIB

Question 1

Compare AFib vs A flutter

Answer 1

Question 2

Most common cardiac arrythmia

Answer 2

AFIB

Question 3

What is AFIB

Answer 3

A supraventricular arrhythmia (above the ventricles) which results from continuous and chaotic atrial activity

Question 4

Risks of AFIB

Answer 4

Rarely life-threatening;

increases the risk of stroke (most severe)

left ventricular dysfunction (loss of ventricular ejection –> fatigue, exercise intolerance, light headed, palpitations)

Non-anticoagulated patients have 3-5 fold increased risk of stroke (generally severe)

Question 5

W\hat is lost on an EKG during Afib?

Answer 5

P- wave is lost

Distance between p waves should be the same

Question 6

What is afib classified as:

Answer 6

an irregularly, irregular rhythm

Question 7

Prevalence Afib

Answer 7

Prevalence increases with age

The age adjusted prevalence is greater in men

10-30% of heart failure patients have AF (lost the atrial kick)

Common and undiagnosed

Question 8

Sx Afib

Answer 8

Fatigue
Palpitations
Chest Pain
dyspnea
Dizziness

Question 9

afib pathophys

Answer 9

ectopic foci that generate electrical impulses

Atria experience rapid irregular and uncoordinated contractions

Because electrical impulses reach the AV node erratically, the ventricular rhythm is irregular

Question 10

Initiating event of AFIB

Answer 10

Factors which destabilize the myocardium such as electrolyte disturbances, ischemic and excessive sympathetic stimulation can contribute to the initiating event

Question 11

How can afib be classified based on structural disease?

Answer 11

Valvular (Warfarin) –> Very significant valve disease (rheumatic fever, valve replacement, or mitral valve repair)

Non-Valvular (DOACS here only)
Absence of rheumatic mitral valve disease, a prosthetic heart valve, or mitral valve repair

“Lone” AF  Young, no heart or pulmonary disease
Absence of clinical or echocardiographic findings of:
Other CVD (including hypertension)
Related pulmonary disease
Cardiac abnormalities; ex/ enlargement of the left atrium
Age under 60 years

Question 12

Paraoxysmal AFib

Answer 12

lasting longer than 30 seconds and self-terminating within 7 days of recognized onset (jump in and jump out)

Question 13

Persistent Afib

Answer 13

continuous AF episode lasting longer than 7 days but less than 1 year

Question 14

Longstanding Afib

Answer 14

continuous AF equal or greater than 1 year in who rhythm control management is being pursued

Question 15

Permenant Afib

Answer 15

continuous AF for which a therapeutic decision has been made not to pursue sinus rhythm restoration

Question 16

What is a substrate?

Answer 16

a pre-existing condition that forms a prerequisite for the induction of an arrhythmia

Examples:

Question 17

triggers

Answer 17

Stimulants
Alcohol
Sleep Depreivation
Emotional STress
Physical Exertiom
Sleep
Digestive

Question 18

Risk factors

Answer 18

HTN
DM

Tobacco
Alcohol

Question 19

Investigating AFib

Answer 19

12-lead ECG

Echocardiogram

LAb Investigations

Question 20

Goals of tx and anticipated outcomes

Answer 20

Prevent stroke or systemic thromboembolism

Cardiovascular risk reduction

Improve symptoms, functional capacity and quality of life

Prevent complications (eg. LV dysfunction and falls)

Outcomes:

Improvement in survival
Reduction in healthcare utilization (ED visits or hospitalization)

Question 21

Afib Diagnosus Scheme

Answer 21

Rate –> Let you be in AFIB but slow down the ventricular rhythym

Rhythym –> Put you back into sinus rhythym

Question 22

CHad 65 Scores

Answer 22

Question 23

Stroke Prevention ChadS 65

Answer 23

Anticoagulate AF in the presence of:

“Valvular AF”
–> Any mechanical heart valve
–> Moderate to severe mitral stenosis (rheumatic or non-rheumatic)
Hypertrophic cardiomyopathy
Hyperthyroidism
Amyloid cardiomyopathy
Non-Valvular AF

Question 24

Stroke Prevention Obese

Answer 24

Higher BMI may be associated with lower stroke rates; higher bleeding rates (obesity paradox)

Standard DOAC dose is reasonable for BMI <40 kg/m2

Question 25

DOAC Use Obese Guidelines

Answer 25

Question 26

Dose Warfarin And DOACS

Answer 26

Question 27

Apixaban when:

Answer 27

Consider Apixaban 2.5 mg po bid if 2 of 1) age 80 years or older, 2) body weight 60 kg or less 3) serum creatinine 133 𝜇mol/L or more;

Question 28

DOAC D.I.

Answer 28

Question 29

DOAC antidote

Answer 29

Question 30

Dosing DOAC differences

Answer 30

Question 31

Dual Tx Doses

Answer 31

1 antiplatlet (P12Y or ASA)

Question 32

Triple Therapy

Answer 32

ASA + P12Y +

Question 33

Do Not use DOACS if:

Answer 33

Mechanical heart valves and significant mitral valve stenosis Use of strong P-gp and 3A4 inhibitors or inducers* (check current product monographs) Pregnancy and lactation (no safety – more heparin product here) Expert bodies indicate need for clinical judgement in extremes of body weight (<50kg; >120kg)** Pediatrics Caution when combined with dual antiplatelets – triple therapy**

Question 34

Monitoring of anticoag

Answer 34

Adherence Frequency of adverse effects (affects adherence) Signs and symptoms of bleeding and bleeding risk factors Regular SCr, CrCl, Hgb

Question 35

Acute Management

Answer 35

Determine if AF is the primary concern or secondary to another acute medical illness Consider hemodynamic stability (blood pressure) Determine whether rate vs rhythm control is appropriate In newly diagnosed AF – rhythm control has been associated with reduced CV death and stroke Determine need for hospitalization Determine need for OAC – start as soon as possible (in ED) if required – CCS algorithm Early follow up

Question 36

Define Rate Control

Answer 36

allow the patient to remain in Atrial Fibrillation, however ensure that the ventricular rate is slowed sufficiently to minimize negative outcomes

Question 37

Benefit of Rhthym COntrol

Answer 37

used in stable patients with recent-onset AF with the decision made on the basis of patient symptoms and goals of care, recognizing that early rhythm control has been associated with a lower risk of stroke and CV death

Question 38

Rhythym control in who:

Answer 38

Recently diagnosed (<1 year) Highly asymptomatic Multiple recurrences Difficulty to achieve rate control Arrthymia-induced cardiomyopathy (Rhythym has more anti death)

Question 39

Acute rate control:

Answer 39

Question 40

Goal of rate control

Answer 40

Reduction in HR of greater than 20% with control of symptoms

Question 41

ND-CCB Examples

Answer 41

Verapamil Diltazem

Question 42

Targets of Rate Control

Answer 42

Resting heart rate < 100 bpm at rest B-blockers or ND-CCBs first line agents Selection of BB vs CCB should be on the basis of patient comorbidities, contraindications and side effects Achieved goal at rest/exercise

Question 43

Ventricular Rate control Choice

Answer 43

Hemodynamic instability --> Digoxin is a poor choice – delayed onset AF associated with exercise, thyrotoxicosis, fever etc. --> ß-blockers are first line --> CCBs are more effective than digoxin Age CCB preferentially used in the young

Question 44

Long term RAte Control

Answer 44

Question 45

Cardioversion and AFIB ANticoagulation

Answer 45

AFIB for more than 48 hours --> need to anticoagulated for 3 weeks before put back into sinus rhthym Do not want to push the clot to the brain Transesophageal ECHO  see if blood clot in atria

Question 46

Risky Rhythym Control

Answer 46

increased the risk of systemic embolism, it is important to start appropriate anticoagulation as time allows for all patients

Question 47

Rhythym COntrol Objectives

Answer 47

Relief of symptoms such as palpitations, fatigue and dyspnea Improve CO and exercise tolerance Prevention of tachycardia-induced myocardial remodeling and heart failure Hemodynamic improvements may take days to weeks

Question 48

Ways to achieve Sinus Rhthym

Answer 48

Rate Control & Await Spontaneous Conversion Electrical (Direct Current) Cardioversion --> Treatment of choice with ventricular rate >150 bpm who are hemodynamically unstable or have serious signs/symptoms i.e., chest pain, pulmonary edema Chemical (pharmacologic) Cardioversion

Question 49

Cardioversion Risk

Answer 49

Must anticoagulate if AF>48 hours (therapeutic INR for 3 weeks before and 4 weeks post conversion to NSR)

Question 50

Patients most likelky to maintain normal sinus rhthym after cardioversion?

Answer 50

Short duration of AF and absence of left atrial dilation

Question 51

Patients who NSR should be attempted?

Answer 51

Recent onset of AF Heart failure Angina Hypotension

Question 52

Cardioversion benefit and risk vs Pharm Conversion

Answer 52

Electrical cardioversion is more effective than pharmacologic cardioversion especially for more prolonged AF episode durations Pharmacologic has the advantage of being immediately feasible in a nonfasting patient as well as avoiding the delays and risks associated with procedural sedation

Question 53

Treatment Indications

Answer 53

Question 54

Before and after cardioversion

Answer 54

OAC for 3 weeks before and 4 weeks after for patients with valvular AF or NVAF >48h

Question 55

Cardioversion acute management Guide

Answer 55

Question 56

Drugs used for pharmacological conversion

Answer 56

Sodium Channel Blockers (Class I agents) and amiodarone are superior to placebo in acute and chronic AF Digoxin, ß-Blockers or CCBs are NOT effective for the conversion of AF to sinus rhythm (Not effective)

Question 57

Side effects pharmacologic conversion

Answer 57

GI related Left Ventricular Depression Negative inotropic effects with many agents Pro-Arrhythmia (life-threatening) ~1-2% Accelerated ventricular response can be seen if converted to atrial flutter Slowing of atrial rate & vagolytic effects of some agents can lead to 1:1 AV conduction

Question 58

Recommendation managing s/e

Answer 58

Concurrent rate control agent

Question 59

Drugs used for Achieveing sinus rhthym

Answer 59

In Paris, friends party

Question 60

Long Term Rhthym Control

Answer 60