AF

Question 1

Causes

Answer 1

Heart failure/ischaemia
Hypertention
MI
PE
Mitral valve disease
Pneumonia
Hyperthyroid
Caffeine, alcohol
Post-op
Low K+ or Mg2+

Question 2

Presentation

Answer 2

Aysmtomatic
Chest pain
Dizzy/faint
Palpitations
Dyspnoea
Irregularly irregular pulse
Signs of non-cardiac disease

Question 3

Investigations

Answer 3

ECG - absent P waves, irregularly irregular QRS
Bloods - U+E, cardiac enzymes, TFTs
Echo - LA enlargement, MV disease, poor LV function, other structural abnormalities

Question 4

Management: acute AF, very ill/haemodynamically unstable

Answer 4

O2, U+E, emergency DC cardioversion, if unavailable try IV amiodarone
Do not delay treatment for anti-coagulation
Treat assoc. illnesses
Control vent rate: 1st line - verapamil or bisoprolol, 2nd line - digoxin or amiodarone
Treatment dose LMWH so can cardiovert even if 48h approaching
If >48h, ECHO to check for thrombus

Question 5

Cardioversion

Answer 5

O2, ITU/CCU, GA or sedation
200 - 360J
Drug: amiodarone IV infusion or flecainide IV infusion

Question 6

Chronic AF principles

Answer 6

Rate control
Anticoagulation
Rhythm control may be appropriate it:
   - symptomatic/CCF
   - younger
   - 1st presentation with "lone" AF (no cause)
   - AF from a corrected precipitant

Question 7

Rate control

Answer 7

Beta blocker or rate limiting CCB 1st line

If this fails, add digoxin, then consider amiodarone

Question 8

Rate control cautions

Answer 8

Only give digoxin monotherapy in sedentary patients

Don’t give beta blockers AND diltiazem or verapamil without advice

Question 9

Rhythm control

Answer 9

Do echo first
Pre-treat for 4weeks with sotalol or amiodarone if risk of failure
Flecainide (no structural heart disease) or IV amiodarone (structural heart disease) first line
AV node ablation, pacing, pulmonary vein embolism options to ask about

Question 10

“Pill in pocket”

Answer 10

Sotalol or flecainide PRN if:
   - infrequent paroxysmal AF
   - BP >100 systolic
   - No LV dysfuntion
Must also anticoagulate

Question 11

Acute AF: anticoagulation

Answer 11

Heparin until full emboli assessment made
If patient high risk of emboli - warfarin aim 2.5 (2-3)
No anticoagulation if: stable sinus rhythm restored, no risk factors for emboli, AF unlikely to reccur

Question 12

CHA2DS2-VaSc

Answer 12

C	Congestive heart failure	1
H	Hypertension (or treated hypertension)	1
A2	Age >= 75 years	2
	Age 65-74 years	1
D	Diabetes	1
S2	Prior Stroke or TIA	2
V	Vascular disease (including ischaemic heart disease and peripheral arterial disease)	1
S	Sex (female)	1
0 or 1 (female) = no anticoagulation
1 (male) = consider anticoagulation
2 = offer anticoagulation

Question 13

Chronic AF: anticoagulation

Answer 13

CHA2DS-VaSc
Warfarin, aim 2-3
Aspirin (less good) or dabigatran (more expensive, less monitoring) are alternatives