Clinical Management of Atrial Fibrillation

Question 1

Arrhythmia

Answer 1

• Abnormal rate or rhythm of heat rate
• Patient >65 or those with hypertension risk

Question 2

Measure pulse

Answer 2

• Measure 30s of heart rate by radial pulse multiply by 2
• Check regularity

Question 3

ECG

Answer 3

• Standard electrogram
• P wave shows that AV node is working properly
• QRS complex which is the depolarization
• T wave shows repolarization

Question 4

What happens happens to ECG at AF

Answer 4

• SA node fire multiple times
• May start in the atrium or anywhere else
• AV node ignore and regulate
• P wave disappear

Question 5

Ectopic beats

Answer 5

• Common and harmless

Question 6

Arterial fibrillation

Answer 6

• Common to sustain normal heart rate and rhythm
• Irregular complex of beats no P wave

Question 7

Ventricular tachycardia

Answer 7

• Regular but fast heart rate

Question 8

Ventricular fibrillation

Answer 8

• Most common life threatening arrhythmias

Question 9

Paroxysmal AF

Answer 9

• Episodes come and go stop within 48hrs of any treatment

Question 10

Persistent AF

Answer 10

• Each episode longer than seven days

Question 11

Long standing persistent AF

Answer 11

• Consistent AF for a yr or longer

Question 12

Permeant AF

Answer 12

• Present for a long time

Question 13

Symptoms of AF

Answer 13

• Asymptomatic in older people
• Palpitations
• Tiredness
• Dizziness
• Chest pains

Question 14

AF prognosis

Answer 14

• Common in older people >65 women
• Most like with people that have hypertension or atherosclerosis
• Good with treatment not life threatening
• Heart failure ventricles work too hard possible stroke

Question 15

Goals of management

Answer 15

• Establish diagnosis
• Control and prevent symptoms so stroke can be prevented

Question 16

Ambulatory ECG

Answer 16

• Paroxysmal AF portable therefore can detect the arrythmias worn for a week

Question 17

Treatment

Answer 17

• Admit if necessary and manage underlying causes and triggers
• Rate control and rhythm control to prevent stroke
• Do thyroid test and undiagnosed hypertension

Question 18

Rate control via beta blockers

Answer 18

Atenolol, metoprolol and bisoprolol

Question 19

Adverse effects of beta blockers

Answer 19

• Bronchospasm and cold extremities
• Sleep disturbances

Question 20

Rate control by rate limiting calcium blockers

Answer 20

• Verapamil and diltiazem

Question 21

Adverse effects of rate limiting calcium channel blockers

Answer 21

• Dizziness palpitations
• GI disturbances
• Bradycardia
• Drug interactions

Question 22

Digoxin monotherapy as rate control

Answer 22

• In people with non paroxysmal AF who are sedentary

Question 23

Adverse effects of digoxin

Answer 23

• Arrythmias, blurred vision
• diarrhea and dizziness

Question 24

Rhythm control

Answer 24

• For people with onset AF with reversible causes
• Can be done within 48hrs

Question 25

Flecainide

Answer 25

- IV loaded then oral dosing - Adverse effects dizziness fatigue fever - Class Ic antiarrhythmic

Question 26

Amiodarone

Answer 26

- Class III antiarrhythmic - Bradycardia - hyperthyroidism - Jaundice

Question 27

Electrical cardioversion

Answer 27

- Patient sedated for short time

Question 28

Catheter ablation

Answer 28

- Carried out in vein of groin - Area of heart causing abnormal electrical discharge destroys radio frequency - AV node pacemaker returns to normal sinus rhythm

Question 29

Stroke prevention

Answer 29

- Thrombosis stagnation of blood in atria and incomplete blood emptying cause embolism in brain - Changes in the vessel wall - Changes in the constituents of the blood - Changes in the blood flow

Question 30

Stroke prevention

Answer 30

- CHA2-DS2-VASc stratification of stoke - Diabetes, heart failure, hypertension and age

Question 31

Score and risk

Answer 31

- >2 then use anticoagulation - 1 and male consider anticoagulation - 0/1 and female then anticoagulation not recommend

Question 32

What do you not offer for someone that has stroke prevention in AF

Answer 32

- No antiplatelet drugs as it is not as effective compared to anticoagulation

Question 33

Bleeding risk

Answer 33

- Risk score calc by abnormal liver function and hypertention - HAS-BLED

Question 34

ORBIT risk score

Answer 34

- less modifiable risks so tend to use HAS-BLED

Question 35

Direct acting anticoagulant

Answer 35

- Dabigatran - direct thrombin inhibitor - Apixaban and Rivaroxaban direct Xa inhibitor

Question 36

Vitamin k antagonist

Answer 36

- Warfarin - Acenocoumarol

Question 37

DOACs vs warfarin

Answer 37

- More common compared to Warfarin - metal heart valve renal impairment put warfarin - Standard dosing and no monitoring INR needed - Large number of interactions - most common adverse effects bleeding - Difficult to reverse the effects

Question 38

DOACs dosing

Answer 38

- Based on renal function and weigh and ensure blood pressure is correct

Question 39

Monitoring

Answer 39

- Annual blood test - > 75 yrs need to be monitored 6 months - Monitor creatinine clearance

Question 40

Annual review

Answer 40

- Check adherence - Specific dosing advice dabigatran keep in packet and rivaroxaban take with food - Missed dose monitoring - Alcohol intake and bleeding

Question 41

INR and risk of VTE

Answer 41

- Normal is 1 and AF reading is 2.5-3