AF Flashcards
4 causes
IHD
HTN
Valve disease
Hyperthyroid
3 complications
Stroke/thromboembolism
HF
Tachycardia induced cardiomyopathy and critical cardiac ischaemia
What is the HR of AF often?
160-180BPM
AF on ECG?
No p waves, irregular ventricular rate, chaotic baseline
Presentation AF
Breathlessness
Palps
Chest discomfort
Syncope/dizziness
Low exercise tolerance, malaise
Polyuria
A complication e.g. stroke, tia
What is paroxysmal AF?
Episodic and less than 48hrs
What could paroxysmal AF be triggered by
caffeine, alcohol
Investigations
Pulse and ECG
Is pulse palpation sensitive and specific?
Sensitive but not that specific
Irregular pulse indicates what is needed?
ECG
Paroxysmal AF susp needs what investigation
Ambulatory ECG
Differentials
Atrial flutter
Atrial extrasystoles
Ventricular ectopics
Sinus tachycardia (>100BMP)
SVTs
Multifocal atrial tachycardia
Management
(admit if complications)
- Rate control- beta blocker or CCB
- Rhythm control in some cases (referral)- electrical or pharmacological (amiodarone, sotalol)
- CHADVASC stroke risk
- Anti-coag- use HASBLED to assess bleed risk. Warfarin or NOAC
- f/u for rate control (effectiveness and tolerability) and anticoag (compliance and SEs)
Identify and manage cause
How do you know whether to give BB or CCB?
Depends on co-morbs- no BB in asthma, no CCB in HF
4 categories AF
first detected episode
paroxysmal
persistent
permanent.
What is permanent AF?
cannot be cardioverted or if attempts to do so are deemed inappropriate. Treatment goals are therefore rate control and anticoagulation if appropriate
What is recurrent AF?
> 2 episodes. This is either persistent or paroxysmal.
Paroxysmal terminates spontaneously (<7 days, usually <24h)
Persistent not self terminating, usually >7days
What are the two key management goals of AF?
- Rate/rhythm control
2. Reducing stroke risk
Do patients always need to be converted back to sinus rhythm?
No, often leave them. Only if e.g. coexistent heart failure, first onset AF or where there is an obvious reversible cause.
What if rate isn’t adequately controlled on one drug?
Use two of these in any combination:
a betablocker
diltiazem
digoxin
What is a risk with cardioversion? How is this mitigated?
the moment a patient switches from AF to sinus rhythm presents the highest risk for embolism leading to stroke.
For this reason patients must either have had a short duration of symptoms (less than 48 hours) or be anticoagulated for a period of time prior to attempting cardioversion.
What does CHADVASC stand for?
Congestive HF
HTN (incl treated)
Age
DM
Prior stroke or TIA (2)
Vascular disease
Sex female
What should your action be based on the CHADVASC?
Offer anticoag (NOAC or warfarin) if >2, and if >1 in men
How could you investigate underlying cause?
Review ECG (prev MI)
Bloods- TFT, FBC, U+E, calcium, Mg, glucose
Transthoracic echocardiogram (if susp underlying cardiac disease)
CXR if lung pathology susp
Management acute AF
- emergency electrical cardioversion
- a) Heparin at presentation if new onset and no anticoag therapy atm
b) oral anticoags IF sinus rythm not restored within 48hrs OR high risk recurrence OR risk stroke
90% AF is due to?
Organic heart disease
