AF

Question 1

chronic AF - principles of management

Answer 1

rate control

rhythm control (cardioversion):
pharmacological or electrical (synchronised DC shocks)

anticoagulation - CHADVASC + HASBLED

Question 2

chronic AF - management

Answer 2

generally rate-control ± anticoagulation

1° - beta blocker (eg bisoprolol) or rate-limiting (reducing) ccb (eg diltiazem)
2° - 2 of beta blocker, diltiazem, digoxin

for 2° - digoxin preferred choice if HF (inotropic), also good if sedentary (doesn’t slow HR in exercise)

Question 3

AF - requirements for rhythm control + factors favouring rhythm control

Answer 3

must have had onset in last 48h OR period of anticoagulation prior to attempting CV

1st presentation
reversible cause eg thyroid, alcohol
acutely unwell - do DC

<65y
symptomatic despite rate control
LVF from AF
congestive heart failure

Question 4

AF - types

Answer 4

first detected episode
paroxysmal - self-terminate, episodes last <7d
persistent - episodes last >7d + don’t self-terminate
permanent - continuous AF that can’t be cardioverted (either CI or not possible) - in this case treatment is rate control + anticoag

Question 5

AF - symptoms

Answer 5

palpitations
SOB
syncope
chest pain

irreg irreg pulse

Question 6

AF - factors favouring rate control

Answer 6

> 65y

hx IHD

Question 7

AF - rhythm control (acute and elective)

Answer 7

acute:
1) treat cause 
<48h - rate or rhythm
>48h or uncertain - rate
haemodynamically unstable - heparin + DC

<48h:

1) heparin
2) DC or pharm cardioversion:
2a) amiodarone - if structural HD
2b) amiodarone or flecainide if no structural HD

> 48h:
1) anticoagulate for at least 3wk before cardioversion
OR do a TOE to exclude thrombus, then heparinise + DC cardiovert immediately
2) electrical cardioversion
3) 4wk anticoagulation
4) chadvasc to determine whether to continue

Question 8

what heart med is contraindicated with beta blockers?

Answer 8

verapamil (also avoid grapefruit juice with verapamil + nifedipine!)

Question 9

AF - investigations

Answer 9

obs
bloods + TFTs
CHADVASC
ECG - if nothing then 24h

Question 10

AF - RFs + precipitants

Answer 10

IHD
RHD
thyrotoxicosis
AHD
HTN