Atrial Fibrillation Flashcards by Zuli Khatun

What is AF?

contraction of the atria in a rapid, uncoordinated and irregular manner due to disorganised electrical activity overriding the normal activity.

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What can AF result in?

Tachycardia, irregularly irregular ventricle contractions, heart failure due to poor filling of the ventricles during diastole and risk of stroke.

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Presentation of AF?

Asymptomatic, palpitation, sob, syncope, associated symptoms stroke, sepsis and thyrotoxicosis

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what are the 2 diagnoses for irregularly irregular pulse?

atrial fibrillation and ventricular ectopics, VE disappear when the heart goes above a certain rate.

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AF on ECG?

absent p waves, narrow QRS complex tachycardia, irregularly irregular ventricle rhythm

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what is valvular AF?

Af with moderate or severe mitral stenosis or mechanical heart valve, assumption is that the valvular pathology has caused AF.

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Non-valvular AF?

without valvular pathology or different pathology i.e mitral regurgitation or aortic stenosis.

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causes of AF?

SMITH
sepsis
mitral valve pethology
ischaemic heart Disease
Thyrotoxicosis
hypertension

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principles of treating AF?

rate/rhythm control
anticoagulation

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why do you need to rate control?

lowering the heart rate increases the time for ventricle to fill with blood and increase cardiac output

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Nice suggest everyone with AF should have rate control unless:

remain symptomatic despite being effectively rate controlled
new onset AF (48h)
reversible cause of AF
Af is causing heart failure

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Rate control options?

beta blocker atenelol 50-100mg
calcium channel blocker diltiazem/verapmil (not preferred in heart failure)
digoxin (sedentary life/risk of toxicity)

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who is rhythm controlled offered to?

symptomatic despite effective rate controlled
new onset AF
AF causes heart failure
AF due to a reversible cause

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how to rhythm control?

1 time cardioversion or rhythm control meds

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difference between immediate and delayed cardioversion?

immediate: haemodynamically unstable or AF less than 48 hours onset
delayed: more than 48 hours AF and stable

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in delayed cardioversion what should be given?

anticoagulant 3 weeks prior in case of emboli and rate control meds

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difference between pharmacological and electrical cardioversion?

pharmacological- flecanide/ amiodarone (patients with structural heart disease)
electrical- sedation or a general anaesthetic and cardiac defibrillator

long term medical rhythm control?

beta blockers first line
dronedarone second line when patient have had successful cardioversion
amiodarone in patients with heart failure or left ventricular dysfunction

what is paroxysmal AF?

comes and goes not more than 48 hours, patients should still be anticoagulated

what is pill in a pocket?

flecanide for AF infrequent episodes without underlying structural heart disease

when to avoid flecanide?

in atrial flutter because it causes 1:1 AV conduction resulting in tachycardia

where does blood stagnate?

atrial appendage

anticoagulation reduces the risk of a stroke by?

2/3

how does warfarin work?

blocks viatmin K and therefore prolongs the time it takes for blood to clot PT

target INR for warfarin is?

2-3

what kind of things can affect warfarin in body?

food rich in vitamin K leafy green vegetables or those affected p450 i.e cranberry juice/alcohol

half life of warfarin is?

1-3 days

how long is half life of NOACs?

7-15 hours, apixaban-12 hours

what can be used to reverse apixaban and rivaroxaban?

andexanet alfa

what can be used to reverse dabigatran?

idarucizumab

DOACs are better then warfarin because?

No monitoring is required No major interaction problems Equal or slightly better than warfarin at preventing strokes in AF Equal or slightly less risk of bleeding than warfarin

what is CHA2DS2VAS score?

Assessing risk of giving someone with AF anticoagulants. C – Congestive heart failure H – Hypertension A2 – Age >75 (Scores 2) D – Diabetes S2 – Stroke or TIA previously (Scores 2) V – Vascular disease A – Age 65-74 S – Sex (female)

what is orbit used for?

Assessing someones bleeding risk whilst on anticoagulants BRAAH Low haemoglobin or haematocrit Age (75 or above) Previous bleeding (gastrointestinal or intracranial) Renal function (GFR less than 60) Antiplatelet medications

another risk of bleeding score is?

HAS BLED H – Hypertension A – Abnormal renal and liver function S – Stroke B – Bleeding L – Labile INRs (whilst on warfarin) E – Elderly D – Drugs or alcohol

What causes AF?

sepsis mitral valve pathology ischaemic heart disease thyrotoxicosis hypertension alcohol and caffeine

normal ECG and paroxysmal atrial fibrillation further investigations?

24 hour ambulatory ECG (holter monitor) cardiac event recorder lasting 1-2 weeks

in delayed cardioversion what should be done?

electrical cardioversion recommended. transeosophageal echocardiography guided cardioversion. Amiodarone before and after electrical cardioversion to prevent AF from recurring.

1st line for anticoagulation?

DOACs

role of apixaban and rivaroxaban?

direct factor Xa inhibitors

dabigatran is?

direct thrombin inhibitor