AF/Flutter

Question 1

What is AF?

Answer 1

Chaotic irregular atrial rhythm at 300-600 bpm
AV node responds intermittently hence an irregular ventricular rhythm.
Cardiac output drops as the ventricles aren’t primed reliable by the atria

Question 2

What is the risk of AF?

Answer 2

embolic stroke

Question 3

What are causes of AF?

Answer 3

Heart failure, hypertension, IHD, PE, mitral valve disease, pneumonia, hyperthyroidism, caffeine, alcohol, hypokalaemia, , post-operative

Question 4

What are symptoms and signs of AF?

Answer 4

Asymptomatic or chest pain, palpitations, dyspnoea, faintness
Signs: irregularly irregular pulse, apical pulse rate is greater than radial rate

Question 5

What does ECG show in AF?

Answer 5

Absent P waves

Irregular QRS complexes

Question 6

How should acute AF be managed?

Answer 6

Stabilise
DC cardiovesion ± amiodarone if unsuccessful

If patient is stable and AF started < 48h ago - rate or rhythm control - for rhythm control DC cardiovesion or flecanide or amiodarone. Start heparin in case cardioversion is delayed.

If patient is stable and AF started >48h ago, rate control with bisoprolol or diltiazem. Patient must be anti coagulated for > 3 weeks for rhythm control

Correct electrolyte imbalances.

Question 7

How is AF treated if it started <48 h ago?

Answer 7

If patient is stable and AF started < 48h ago - rate or rhythm control - for rhythm control DC cardiovesion or flecanide or amiodarone. Start heparin in case cardioversion is delayed.

Question 8

How is AF treated if it started >48h ago?

Answer 8

If patient is stable and AF started >48h ago, rate control with bisoprolol or diltiazem. Patient must be anti coagulated for > 3 weeks for rhythm control

Question 9

What are the goals of managing chronic AF?

Answer 9

Rate control and anticoagulation

Question 10

When may rhythm control be appropriate in chronic AF?

Answer 10

Symptomatic or CCF
Younger
Presenting for first time with lone AF
AF from a corrected precipitant

Question 11

What is used for rate control in chronic AF?

Answer 11

Beta blocker - bisoprolol
Rate-limiting CCB - diltiazem (do not use beta-blockers with verapamil
If this fails, add digoxin, then consider amiodarone.

Aim for HR <90 at rest and 200-age on exertion

Question 12

What is used for rhythm control in chronic AF?

Answer 12

Elective DC cardioversion
Elective pharmacological cardioversion:
Flecanide first line
If scar tissue from MI or structural heart disease use IV amiodarone

Question 13

What can be done for refractory AF?

Answer 13

AVN ablation with pacing

Question 14

What is paroxysmal AF? How is it treated? What is persistent AF?

Answer 14

Episode of AF that terminates spontaneously or with intervention in less than seven days.
Sotalol or flecanide PRN

Persistent - lasts > 7 days

Question 15

How is atrial flutter managed?

Answer 15

Rate and rhythm control
Anticoagulation
DC cardioversion preferred to pharmacological cardioversion
IV amiodarone if rate control is difficult

Question 16

What anticoagulation is used in acute AF?

Answer 16

Heparin until full risk assessment for emboli is made.
Use a DOAC or warfarin (target INR 2-3) if high risk of emboli (past ischaemic stroke, TIA or emboli, 75 or older with hypertension, DM, coronary or peripheral arterial disease, CCF.

Use no anticoagulation is table sinus rhythm has been restored, there are no risk factors for emboli and AF recurrence is unlikely.

Question 17

What are risk factors for emboli?

Answer 17

past ischaemic stroke, TIA or emboli, 75 or older with hypertension, DM, coronary or peripheral arterial disease, CCF.

Question 18

Describe anticoagulation in chronic AF

Answer 18

Assess risk of clot using CHA2DS20VASc score for embolic stroke risk and balance against risk of bleed using HAS-BLED score.

Use a DOAC or warfarin for long term anticoagulation