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RACP Written 2018 > Cardiology - Arrythmias: AF > Flashcards

Cardiology - Arrythmias: AF Flashcards

(41 cards)

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1
Q

AF Risk Factors:

A

DEMOGRAPHICS

  • western countries
  • males
  • Caucasians

SYSTEMIC

  • Hypertension
  • obesity
  • OSA
  • diabetes
  • hyperthyroidism

STRUCTURAL HEART

  • HOCM
  • Valvular heart disease (esp MS)
  • ACS with HF (NOT IHD itself)

OTHER

  • hypomagnesaemia (50 times more likely)
  • alcohol (esp binge drinking)
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2
Q

Demographic RF for AF

A
  • western countries
  • males
  • Caucasians
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3
Q

Systemic RF for AF

A
  • Hypertension
  • obesity
  • OSA
  • diabetes
  • hyperthyroidism
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4
Q

Structural heart disease RF for AF

A
  • HOCM
  • Valvular heart disease (esp MS)
  • ACS with HF (NOT IHD itself)
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5
Q

Nonspecific RF for AF

A
  • hypomagnesaemia (50 times more likely)

- alcohol (esp binge drinking)

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6
Q

Definition of paroxysmal AF

A

Self terminates within 7 days

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7
Q

Persistent

A

> 7 days

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8
Q

Longstanding persistent

A

> 12 months

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9
Q

Permanent

A

Not for rhythm strategies

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10
Q

AF can develop post cardiac surgery.
How often?
When is greatest risk?
When can you stop anti-arrythmics?

A

Develops in 25%

Greatest risk post op on Day 2 and 3

Usually self-limited
Can stop antiarrythmics by 2-3 months post op

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11
Q

Describe the pathology behind the three phases of AF

A

Phase 1: Paroxysmal AF
- stretch increases propensity for PULMONARY VEIN focuses to develop due to stretch sensitive ion channels

Phase 2: Persistent AF
- over time there is remodelling of left atrium

Phase 3: Permanent AF
- With more time it is more difficult to maintain sinus due to gross electrical and structural atrial remodelling.

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12
Q

What can prevent AF?

A
  • Manage risk factors
  • Mediterranean diet with extra virgin olive oil or mixed nutes
  • Being fit
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13
Q

Once you have an episode of AF what NON-PHARMA measures can prevent RECURRENCE?

A

Weight loss (if >10%) causes SIX TIMES decreased recurrence rate

Increased fitness

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14
Q

When is urgent cardioversion indicated, and when doing it how do you sync the charge?

A

Indicated urgently if HD compromise

Synchronise the R wave to AVOID R-on-T event which provokes VT

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15
Q

? do you need anticoagulation for AF?

A

If AF is definitely <48 hours then you don’t need anticoagulation

BUT

If uncertain duration or >48 hours then:

  • TOE to look for thrombus in LV
  • post chemical cardioversion anticoagulation for 3 weeks
  • post-procedure anticoagulation for 4 weeks
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16
Q

Agents with PROVEN EFFICACY for pharmacologic conversion

A 
Amiodarone
Flecainide
Quinidine
Dofetilide
Ibutilide
Propafenone
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17
Q

Agents which are LESS EFFECTIVE at pharmacological conversion

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A 
beta blockers (including sotolol)
CCBs
Digoxin
Disopyramide
Procainamide
18
Q

Why is CHA2DS2-VASc better than CHADS2?

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A

It is more SENSITIVE

19
Q

On what score do you anticoagulate on CHA2DS2-VASc

20
Q

Components of CHA2DS2-VASc

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A 
Congestive HF (+1)
Hypertension (+1)
Age >=75 (+2)
Diabetes mellitus (+1)
Stroke or TIA (+2)
Vascular disease (+1)
Age 65 - 75yrs (+1)
Sex female (+1)
21
Q

Which components of CHA2DS2-VASc earn 2 points?

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A

Age >= 75yrs

Stroke or TIA

22
Q

What are the components of HAS-BLED?

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A

+1 point each:

  • Hypertension
  • Abnormal renal Cr>200 or liver (3 x normal)
  • Stroke hx
  • Bleeding hx
  • Labile INR (time in therapeutic range <60%)
  • Elderly >65yrs
  • Drug or alcohol history (>8SD per week) or drugs that cause bleeding
23
Q

What HAS-BLED score is considered HIGH RISK?

24
Q

In anticoagulation of non-valvular AF what NOACs are NONINFERIOR to warfarin AND have lower ICH risk?

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A

Dabigatran 110mg BD

Rivaroxaban 20mg daily

25
In anticoagulation of non-valvular AF what NOACs are SUPERIOR to warfarin AND have decreased ICH risk?
Apixaban 5mg BD OR Apixaban 2.5mg BD if >=2 of age>80, Cr >133 or weight <60kg
26
In using apixaban for stroke prevention in nonvalvuar AF when must the lower dose 2.5mg BD be used?
If 2 or more of: - age >80yrs - Cr >133 - weight 60kg
27
In anticoagulation of non-valvular AF what NOACs cmopared to warfarin have a MORTALITY benefit?
Apixaban
28
In anticoagulation of non-valvular AF what NOACs have a HIGHER GI BLEED RISK?
Dabigatran Rivaroxaban (Apixaban has no difference in GI bleed rate!)
29
In AF management should we use rate control or rhythm control in preference?
NEITHER! | Rate control is NONINFERIOR to rhythm control for both STROKE and SURVIVAL
30
BUT if we definitely wanted to give RHYTHM control in management of AF who would have a HIGHER mortality with RHYTHM control? (and therefore should definitely be rate controlled only!)
Elderly Coronary artery disease CCF
31
In tachycardia-induced cardiomyopathy what should we aim for the HR?
<80bpm
32
If someone has SYMPTOMS would rate or rhythm control be preferred?
If symptoms then aim for RHYTHM control
33
Is lenient rate control (aim <110bpm) or strict rate control (aim <80bpm) better?
If NOT with underlying cardiomyopathy then there is no significant difference EXCEPT lenient will have less clinic visits
34
If deciding to rate control someone in AF what medications are used first line? And if they have pre-excitation syndrome what must you avoid?
BB and CCBs first line BUT If pre-excitation: - AVOID CCB and digoxin - GIVE beta blockers, flecainide or amiodarone
35
In AF when maintaining sinus rhythm, what are the issues with Class I Sodium Channel Blockers?
Class I Sodium Channel Blockers (ie flecainide and propafenon) - negative inotrope and pro-arrhythmic effects - Don't use if STRUCTURAL heart disease - AVOID in coronary heart disease and CCF - Can result in organisation to a flutter with 1:1
36
In AF when maintaining sinus rhythm, what are the issues with Class III Agents?
Class III agents such as sotolol, amiodarone and dofetilide - able to be used in coronary artery disease and structural heart disease - Risk of QTc prolongation and torsades
37
What is the BEST INDICATION to use catheter ablation and pulmonary vein isolation in management of AF?
Symptomatic paroxysmal AF refractory or intolerant of AT LEAST 1 Class I or Class III antiarrythmic
38
In catheter ablation of AF when is it best done?
Early in AF without significant atrial enlargement
39
If able, why is catheter ablation better than antiarrhytmics in AF?
- better at preventing recurrent atrial tachycardias - reduced cardiovascular hospitalisations - better QoL
40
Complications with catheter ablation in AF?
- tamponade (1%) - Stroke (0.5-1%) - Phrenic nerve paralysis - Pulmonary vein stenosis (presents years or months later with SOB and haemoptysis)
41
Complications of AF?
- increased all-cause mortality - Stroke rate 5% per year (compared to 1% if non-AF) - worsened HF - Tachycardia associated cardiomyopathy - Increased risk dementia - increased risk nursing home placement

RACP Written 2018 (167 decks)

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