Atrial Fibrillation

Question 1

What is atrial fibrillation

Answer 1

Irregularly Irregular atrial firing due to AV Delay

Question 2

What is the epidemiology of AF

Answer 2

Most common Cardiac arrythmia

Increases with age

Question 3

What is the pathology behind AF

Answer 3

Inflammation and fibrosis dilates the atria causing change in the refractory period.
Electrical re-entrant pathway is conducted in the atria leading to uncoordinated contractions.
The AVN only conducts some of these contractions leading to irregular ventricular response (Atrial Spasm and Atrial pooling)

Question 4

How would you describe the Pulse in AF

Answer 4

Irregularly Irregular

Question 5

What are some causes of AF

Answer 5

Heart fail
HTN
Secondary to mitral stenosis

Question 6

What are the ris factors of AF

Answer 6

>60
Diabetes
HTN
CAD
MI

Question 7

What is the symptoms of AF

Answer 7

Palpitation
Chest pain
SOB
Dizzy

Question 8

What are the signs of AF

Answer 8

Irregularly irregular pulse
Apical>Radial pulse
Heart fail
Hyperthyroid
Alcohol Excess

Question 9

What does an ECG show for AF

Answer 9

Irregular Pulse
Narrow QRS
No P waves
Variable Ventricular rate
Absent Isoelectric line

Question 10

How would you define AF

Answer 10

Ventricular rate >100bpm

Question 11

What is the first rule of management of AF

Answer 11

ABCDE
Asses haemodynamic stability
-Shock = end organ hypoperfusion
-Syncope = Brain hypoperfusion
-Chest pain = MI
-Pulmonary oedema = Heart fail

Question 12

When should you offer Immediate DC CARDIOVERSION

Answer 12

If the patient is unstable

Question 13

How would you treat the reversible causes of AF

Answer 13

Infection - give antibiotics and fluid
Dehydration - give fluids
Replace abnormal electrolytes

Question 14

When would you offer Rate control

Answer 14

Everyone with AF EXCEPT….

• AF with reversible cause
• Heart failure
• New AF onset

Question 15

What would you offer for rate control of AF

Answer 15

Beta Blocker (Bisoprolol) or Rate limiting CCB (Diltiazem)
Digoxin

Question 16

When would you offer digoxin

Answer 16

Non paroxysmal AF
Hypotensive patient
Existing Heart fail
Avoid in young patients (high mortality)
Normally used 2nd to beta blocker

Question 17

Which beta blocker cannot be used in AF

Answer 17

Sotalol

-Rhythm control action

Question 18

When are Beta blockers Contraindicated

Answer 18

COPD, Asthma and Hypotension

Question 19

Which two CCB are commonly used in AF (Non-dihyropyridine)

Answer 19

Diltiazem
Verapamil
-Not used in Hospital because negatively inotropic so CI in Heart fail

Question 20

How can you achieve Rhythm control

Answer 20

Electrical cardioversion

Pharmacological Cardioversion

Question 21

When can a patient have immediate DC cardioversion

Answer 21

When AF is Acute <48hrs

Question 22

What is the management of AF if it has been over 48hrs or the cause is uncertain

Answer 22

Anticoagulation 3 weeks before DC cardioversion

Do a Transoesophageal ECHO to rule out LA thrombus

Question 23

What is the pharmacological cardioversion drugs used in AF

Answer 23

Flecainide (Pill in pocket)
Amiadarone(Rate and rhythm control)
Sotalol (Last resort)

Question 24

What AF drug would you give to a patient who is young with structurally sound hearts

Answer 24

Flecainide

They cause arrythmias in patients with heart structure problems

Question 25

What AF drug would you give to elderly patients

Answer 25

Amiadarone | Highly effective but give to elderly because they have many side effects

Question 26

Why should anticoagulation be given with AF

Answer 26

AF has a high chance of thromboembolism thus stroke so risk needs to be decreased

Question 27

What is the scoring system for Anti-coagulation typically with AF

Answer 27

``` CHADS2VASc C- Cardiac fail = 1 H- HTN = 1 A - Age over 75 = 2 D - Diabetes Mellitus =1 S - Stroke/TIA = 2 V - Vascular disease = 1 A- Age 65-74 = 1 Sc - Female = 1 ```

Question 28

What score is needed on CHADS2VASc for anticoagulation

Answer 28

``` Male = 1 or more Female = 2 or more ```

Question 29

How would you assess bleeding risk with anticoagulation

Answer 29

``` HASBLED H- HTN = 1 A- Abnormal renal/Liver function = 1 each S- Stroke = 1 B- Bleed is major = 1 L- Labile INR = 1 E- Elderly over 65 = 1 D- Drugs and Alcohol = 1 each ```

Question 30

What is the newly presented score for measuring anticoagulation

Answer 30

ORBIT score - Sex - Haemoglobin (<13M OR <12F) - Age - Bleeding - Renal function (eGFR<60) - Antiplatelet use

Question 31

Why is there a high risk of stroke from AF

Answer 31

Blood stagnates in the atria due to invariable contractions and poor emptying Blood embolises and can travel to the brain via the carotids

Question 32

What are the three forms of anticoagulation used in AF

Answer 32

DOAC Warfarin LMWH

Question 33

Why are DOACS the drug of choice for anti coagulation

Answer 33

Edoxaban-Apixaban-Dabigatran Do NOT require monitoring Less bleeding risks than Warfarin But has short half life

Question 34

What are the characteristics of Warfarin

Answer 34

Prothrombotic so needs LMWH initially Requires INR monitoring But has longest half life The only drug for Valvular AF

Question 35

Give an example of LMWH

Answer 35

Enoxaparin

Question 36

What is Atrial Ablation

Answer 36

Intervention which destroys conduction tissue

Question 37

What are the complications of AF

Answer 37

Heart fail Embolism (stroke and ischemia) GI Bleed

Question 38

What are the types of intervention for AF

Answer 38

``` DC cardioversion (Rhythm control) Rate control Pharmacological Cardioversion Anticoagulation Atrial Ablation ```

Question 39

What is the HASBLED score

Answer 39

Asses risk of major bleed in AF w/anticoagulation | >3 = regular review