AF

Question 1

What does AF look like on ECG?

Answer 1

• Irregularly irregular tachy
• Absent P waves
• Narrow QRS

Question 2

What causes AF?

Answer 2

Disorganised electrical activity in the atria, overriding the normal activity of the SAN

Question 3

What can AF lead to?

Answer 3

Clots

- Embolic strokes (ischaemic)

Question 4

How does AF present?

Answer 4

Often asymptomatic/incidental

• Palpitations
• Dyspnoea
• Syncope/dizziness
• Symptoms of associated condition e.g. stroke, thyrotoxicosis

Question 5

What are the two differentials for an irregularly irregular pulse?

Answer 5

• AF

- Ventricular ectopics

Question 6

What are the most common causes of AF?

Answer 6

SMITH

• Sepsis
• Mitral valve pathology
• Ischaemic heart disease
• Thyrotoxicosis
• HTN

Question 7

What are the principles of AF treatment?

Answer 7

• Rate vs Rhythm

- Anticoagulants

Question 8

When should rate control be used?

Answer 8

ALL EXCEPT:

• reversible cause of AF
• AF onset in last 48 hours
• AF causes HF
• Remain symptomatic despite effective rate control

Question 9

What rate control drugs are there?

Answer 9

1- Beta-blocker- atenolol
2- CCB- diltiazem (not in HF)
3- Glycoside- digoxin (only in sedentary people)

Question 10

When is cardioversion used in AF?

Answer 10

Immediately if AF is less than 48hrs old

Delayed of it is over 48hrs and they are stable

Question 11

How does delayed cardioversion work?

Answer 11

• Delay for at least 3 weeks with anticoagulation
• Anticoag. because a clot may have developed in that 48hr period, and cardioversion would cause an embolic stroke
• Give rate control whilst waiting

Question 12

What drugs are used for pharmacological cardioversion?

Answer 12

• Flecainide

- Amiodarone (esp. with structural heart disease)

Question 13

What other way to cardiovert is there?

Answer 13

Electrical cardioversion

Question 14

What long term rhythm control is used?

Answer 14

• Beta-blocker is first line for both rate and rythm
• Dronedarone post cardioversion
• Amiodarone in HF or LVF

Question 15

What is paroxysmal AF?

Answer 15

AF that comes and goes, lasting up to 48 hours a time

Question 16

What is the ‘pill in the pocket approach’?

Answer 16

Patient carries flecainide, and uses it when they get paroxysmal AF symptoms

Question 17

When should flecainide be avoided and why?

Answer 17

Atrial Flutter

- Causes 1:1 conduction (Atrial rate of 300 goes to ventricle)

Question 18

How is anticoagulation use decided?

Answer 18

CHADSVASc vs HASBLED

Question 19

Outline CHA2DS2 VASc.

Answer 19

Congestive HF
HTN
Age 75+ (2)
Diabetes
Stroke (2) Tia (1) 

Vascular disease
Age 65-74
Sex (female)

Question 20

Outline HAS BLED.

Answer 20

HTN
Abnormal renal/liver function
Stroke

Bleeding
Labile INRs on warfarin
Elderly
Drugs or alcohol use

Question 21

Why does CHA2DS2VASC usually outweigh the risk of HASBLED?

Answer 21

Bleeds can be treated, strokes can be life-changing.

Question 22

How does warfarin work?

Answer 22

Vit K antagonist, stopping factors 2,7,9 and 10

Question 23

What is special about factor 10?

Answer 23

It’s the point at which the extrinsic and intrinsic clotting pathways meet

Question 24

What is the target INR of warfarin?

Answer 24

2-3

Question 25

What juice should be avoided with warfarin?

Answer 25

Cranberry- raises INR

Question 26

What advantages do DOACs have?

Answer 26

• No monitoring required
• No major interactions
• Equal/slightly better at stroke prevention than warfarin
• Equal/slightly less risk of bleeding than warfarin

Question 27

What CHA2DS2VASC requires anticoagulation?

Answer 27

Males- 2

Females- 3 (since female is already a factor)