AF

Question 1

How does AF appear on an ecg?

Answer 1

Irregular RR intervals, no distinct p waves, rapid and chaotic atrial activity.

Question 2

What is paroxysmal AF?

Answer 2

Recurrent ≥ 2 episodes that terminate within 7 days (≤ 48h terminated with CV

Question 3

What is persistant AF?

Answer 3

Continuous>7 days or AF ≥ 48h in which decision made to perform CV

Question 4

What is long standing AF?

Answer 4

Continuous AF of >12 months duration

Question 5

What is permanent AF?

Answer 5

Joint decision by patient and Clinician to cease further attempts to restore or maintain SR

Question 6

What are the main symptoms of AF?

Answer 6

Palpitations, shortness of breath, fatigue, dizziness, syncope.

Question 7

Which conditions can be commonly associated with AF?

Answer 7

Hypertension
Heart failure
Diabetes
Obesity
Sleep apnoea/ chronic lung disease
Valvular heart disease (MV disease)
Congenital heart disease
Coronary artery disease
Thyroid disease
Chronic kidney disease (CKD)

Question 8

What happens in atrial ablation?

Answer 8

The ablation points are centred in the left upper chamber of the heart, or left atrium. A series of ablation points is used to establish a line of lesions. These lines are supposed to block the trigger points of Atrial Fibrillation and create a barrier to the propagation of the arrhythmia. As stated, the lesions target the entrance of the pulmonary veins, of which usually two right and two left ones are found. The lesion points are applied inside the left atrium a few millimeters from the pulmonary vein insertion in the body of the left atrium. This region is known as pulmonary vein antrum. The end point of the procedure is to electrically isolate the pulmonary veins - pulmonary vein isolation or PVI. (wiki)

Question 9

Again

Answer 9

Electrical isolation of the pulmonary veins
Prevents “triggers” and “drivers” of AF
Creates electrically inexcitable “scar” around the PV’s which blocks PV ectopics from entering the left atrium
2-3 hour procedure under conscious sedation with opiate analgesia
Prior anticoagulation with warfarin (or NOAC)
Percutaneous access via femoral veins
Transseptal puncture to access the left atrium (SVC goes to right atrium first)
~ 70% success rates with need for multiple procedures in 25%
2-3% major complication (stroke, tamponade, PV stenosis)

Question 10

What are the main objectives in the management of AF?

Answer 10

Stroke prevention, symptom relief, ventricular rate control, correction of rhythm disturbance, optimum management of concomitant cardiovascular disease.

Question 11

What are the factors of the CHADSVAS score?

Answer 11

Congestive heart failure/ left ventricular systolic dysfunction 1
Hypertension 1 (consistently over 140/90)
Age >75 2
Diabetes 1
Stroke/TIA 2 (prior stroke or TIA or thromboembolism)
Vascular disease 1
Age 65-74 1
Sex category (female) 1

(female sex category only counts if there are other risk factors present)

Question 12

What does the chadvas score determine?

Answer 12

The risk of having a stroke in AF

Question 13

What is the maximum score in the chadvas score?

Answer 13

9

Question 14

What is the HASBLED score used for?

Answer 14

This is used to assess bleeding risk in AF

Question 15

What does HASBLED stand for?

Answer 15

Hypertension 1
Abnormal renal or liver function 1 or 2 (dialysis/ transplant/ creat >200, Liver disease = cirrhosis/ bilirubin >x2, AST/ ALT > 3x normal)
Stroke 1 (NOT TIA)
Bleeding 1 (previous major bleed or predisposition to bleeding)
Labile INRs 1
Elderly >65 1
Drugs or alcohol 1 point each

Question 16

What is the maximum hasbled score?

Answer 16

9

Question 17

If the cha2ds2vas score is >2, what should be offered?

Answer 17

Warfarin or novel anticoagulants, dabigatran, rivaroxaban, apixaban.

(if >1 consider anticoagulation)

Do not use aspirin as anti-coag

Question 18

When should rate and rhythm control be offered first line to AF patients?

Answer 18

If the AF has a reversible cause,
who have HF thought to be caused by AF,
who have new onset AF

Question 19

Which drugs are used for rhythm control?

Answer 19

Standard beta blocker ( not soltolol), also rate-limiting calcium channel blocker (diltiazem).

Question 20

When should digoxin only be used?

Answer 20

In non-paroxysmal AF for sedentary patients or if in heart failure

Question 21

NB:

Answer 21

Do not use amiordarone for long term rate control

Question 22

What are the options for rhythm control?

Answer 22

Antiarrhythmic drug therapy
Beta-blockers
Flecainide, propafenone (pill in the pocket vs regular) 
Sotalol, dronedarone, amiodarone
Cardioversion
Chemical
Electrical
Catheter ablation

Question 23

When can you use cardioversion?

Answer 23

DC cardioversion if AF < 48 hours
If AF > 48 hours, requires a period of therapeutic anticoagulation minimum 3 weeks before and 4 weeks afterwards (warfarin with INR>2 or NOAC)

3 CV 4

Question 24

What percentage of patients who have cardioversion will have a recurrence within 12 months?

Answer 24

50%

Question 25

Which drug can you give 4 weeks before cardioversion to help improve success rates?

Answer 25

Amiordarone

Question 26

What questions to you want to ask a patient with ?AF?

Answer 26

How long do episodes last?
How many a day/week?
Associated chest pain, syncope, dizziness, breathlessness, nausea, exercise worsen it or induce it (walking up stairs etc)?
Caffeine intake
PMH PDH
FH

Question 27

What investigations do you do in any patient with suspected AF?

Answer 27

ECG, bloods- FBC u&es, lfts, hba1c, tft, lipids, bnp?, ?echo if suspect HF

Question 28

BNP?

Answer 28

Brain natriuretic peptide or B-type natriuretic peptide (BNP) (also ventricular natriuretic peptide or natriuretic peptide B) is a 32-amino acid polypeptide secreted by the ventricles of the heart in response to excessive stretching of heart muscle cells (cardiomyocytes). The release of BNP is modulated by calcium ions. -HF