AF

Question 1

Epidemiology – AF:

Answer 1

u Most common sustained cardiac arrhythmia
u Affects at least 1-2% of population (likely substantially
higher)
u Prevalence and incidence increases with age
u 4% at 65 years of age
u 12% at 80 years of age
u AF known to affect 200,000 to 250,000 Canadians
(estimated that actually up to 1 million affected)
u AF is associate with reduced quality of life,
functional status, cardiac performance and
survival
u AF is independently associated with a 1.5 to 4
fold increase risk of mortality, predominantly
due to thromboembolic risk (mainly stroke) and
ventricular dysfunction

Question 2

Consequences of AF:

qivering

Answer 2

Atria:
u Multiple re-entry loops causing
disorganized atrial activity
u Rate = 400-600 bpm
u Ineffective atrial contraction
leads to stasis of blood
u Potential thrombosis in left atria
or left atrial appendage

stasis of blood with not good contraction –> leads to clots
Virchow’s triad

Question 3

Cardioembolic Stroke

Answer 3

u Thrombus may embolize from the heart and
travel to the brain to cause a cardioembolic
stroke
u Stroke presentation varies depending on
affected area of brain (80% affect the middle
cerebral artery or anterior cerebral artery)
u 70% of stroke with AF are either fatal or leave
severe residual deficits

Question 4

Consequences of AF:
Loss of Atrial Kick:

Ventricular Response:

Answer 4

u Atria contract in a very rapid and irregular
rhythm impairing emptying of blood into ventricles
u Atrial kick can account for up to ~20% of cardiac
output in NSR

u Impulses from atria are irregular and reach the AV
node (gatekeeper) at varying times
u The impulses that pass through the AV node cause
the ventricles to contract at an irregular rhythm (faster than usual)
u Increased rate = up to 120 to 180 bpm
AV node is gatekeeper

Question 5

heart pumping frequently

Answer 5

A) Short of breath
B) Heart pounding
C) Tired
B) They enlarge

Increased heart rate can
cause the heart to work too
hard and cause enlargement
and damage. This is called
tachycardia – induced
cardiomyopathy

Question 6

Symptoms of AF:

Answer 6

Patients with AF may be completely asymptomatic
to highly symptomatic
u Initial presentation of AF could be cardiac
symptoms, heart failure symptoms, cardioembolic
stroke or systemic embolism

Question 7

Presentation of AF:

Answer 7

Thrombus
Formation:
•Cardioembolic Stroke
•Systemic Embolism

Rapid Heart Rate:
•Symptoms: palpitations, chest pain, hypotension

Loss of Atrial Kick:
•Heart Failure
Symptoms: Dyspnea, fatigue,
↓ exercise tolerance

Question 8

Major Goals and Expected Outcomes:

Answer 8

Improve Survival

1. Thrombus
Formation:
• Prevention of
Cardioembolic
Stroke and
Systemic
Embolism

2. Rapid Heart Rate:
• Improvement of
Symptoms,
Functional
Capacity and
Quality of Life

Reduce Health
Care Utilization
1. Loss of Atrial Kick:
• Prevent
Complications
such as LV
Dysfunction

Question 9

diagnosis of AF

Answer 9

slie 22

Question 10

Risk Factors

Answer 10

AF-induced substrate
(e.g. electrical & structural remodeling)
Non-modifiable Substrate
(e.g. Age, Sex, Genetics)
Modifiable Substrate
(e.g. hypertension, obesity, sleep apnea)

HTN, diabetes, tobacco, alochol

Neurohormonal activation
• Structural, Electrical or
Autonomic Remodeling
• Inflammation and oxidative stress

Question 11

2020 AF Guideline Recommendations:

u In patients with AF or high risk of AF:

Answer 11

u Systemic approach to identification of modifiable risk
factors/conditions associated with AF
u Strict Guideline adherent management of these risk
factors/conditions
Desired Outcomes: Prevent AF occurrence/recurrence and
decrease symptom burden

Question 12

ole of Pharmacist in AF

Answer 12

qPrevention of AF
qDetection of AF
qAssessment of Patient with AF
qManagement of Medications
qMonitoring of Medications and of
Patient

Question 13

prevention

Answer 13

Sleep Apnea
- CPAP for moderate-severe OSA (AHI ≥ 15/hour)
Regular assessment of CPAP adherence (continuous pressure overnight, not holding breath)

Weight Loss
Target a weight loss of ≥10% to a
BMI of less than 27 kg/m2

Diabetes
Target a HbA1c of ≤7.0%

Blood Pressure
Target ≤ 130/80 mmHg at rest and ≤ 200/100 mmHg at peak exercise.
ACE-I or ARB may be preferred.

Exercise
1. Moderate intensity aerobic exercise ≥ 30
minutes a day at least 3-5 days per week
(target ≥ 200 minutes weekly).
2. Resistance exercise 2-3 days per week.
3. Flexibility exercises at least 10 minutes
per day at least 2 days per week in those
>65 years of age

Alcohol and Tobacco
Limit to ≤ 1 standard drink1 per day.
Complete abstinence from alcohol may
be preferred in selected patients.
Target complete abstinence from
tobacco-related products.

Question 14

Diagnosis:

• Diagnosis of AF is based upon ECG

Answer 14

1) Irregular Absence of P waves ( hard to find P waves)
2) Irregular intervals of QRS complexes (ventricles is not beating properly )
3) Irregularly, irregular supraventricular tachyarrhythmia (no regular QRS intervals)

Question 15

Patterns/Duration of AF:

Answer 15

AF can be self-terminating and may be difficult to detect

paroxysmal af

Question 16

AF Diagnosis: Holter Monit

Answer 16

u Patients may have NSR as their
predominant rhythm with brief
bouts of AF
u Holter monitor allows for > 24
hour monitoring of ECG

hard to order >24 hrs

Question 17

AF Diagnosis: Implantable Device

Answer 17

implantable loop recorder
can last p to 2 years
can record the arrhthmia

Other Ways to Detect AF:
pulse palpitation, bp monitor, non 12 lead ECG
smartphone

Question 18

2020 AF Guideline Recommendations:

Answer 18

Opportunistic screening for AF should be conducted in people >65 years of age at the time of medical
encounters
u Practical Tip: Screening can be efficiently and costeffectively performed using pulse checks during
u Desired Outcomes: Early detection and treatment of
AF can prevent adverse events

Question 19

Opportunistic AF screening for individuals

≥ 65 years at time of medical encounter

Answer 19

Pulse-based Screening
• Pulse palpation
• Blood Pressure monitors
• Plethysmograph

Rhythm-based Screening
• Single-lead ECG devices

Atrial Fibrillation Suspected
Perform 12-lead ECG

No AF confirmed:
Perform additional
rhythm-based monitoring

diagnosis of AF:
Stroke Prevention
Management of arrhythmia
Assessment of Risk factors

Question 20

Other Investigations for AF (2)

Answer 20

u Echocardiogram
u Transthoracic Echocardiogram (TTE) recommended in all patients
u Identify LA size, LV hypertrophy or dysfunction, valvular heart
disease, and possibly LAA thrombus (usually need
Transesophageal Echo - TEE)

u Blood work
u CBC, coagulation profile, electrolytes, renal, thyroid, and liver function tests
uDetermine if underlying cause
uPrepare for possible therapy

Question 21

AF Classification

Answer 21

Classification of AF
guides treatment
decisions

Structure of AF
uValvular AF
uNon-Valvular AF

Duration
uParoxysmal
uPersistent
u“Longstanding” persistent
uPermanent

Question 22

Structural Classification
CLOT RISK
ASSESSMENT
DETERMINES
TREATMENT
SELECTION

Answer 22

Valvular AF:
AF in the presence of any
mechanical heart valve or in the
presence of moderate to severe
mitral stenosis 

risk of stroke = 17%/yr

NonValvular AF:
AF without mechanical heart valve of moderate to severe mitral stenosis
Risk of stroke ~4.5%/yr

Question 23

Duration of AF

Answer 23

Paroxysmal AF: Continuous AF episode lasting >30
seconds but terminating within 7 days of
onset
- rate of stroke = 2.1
Persistent AF: Continuous AF episode lasting >7 days
but terminating within 1 year of onset
- rate of stroke = 3.1
“Longstanding” Persistent AF: Continuous AF > 1 year for which rhythm control is being pursued
Permanent AF Continuous: AF for which therapeutic
decision has been made to not pursue
rhythm restoration (high chance it wont go back normal)
- rate of stroke = 4.2% (increases the longer you have it)

CLOT RISK IS SIGNFICANT IN ALL PATTERNS OF AF

Question 24

most common thromotic consequence of af
type of clot that forms w/ stasis of blood:
best option for tx of red clots

Answer 24

cardioembolic stroke
red clot
- endothelial injury -> white clot (atherosclerosis, cholesterol) -> use antiplatelets (platelets and strans of fibrin)
- DVT due to stasis -> red clot
- red clot tx -> anticoagulants (erythrocytes in fibrin matrix)