AF Management

Question 1

what are the 3 types of AF?

Answer 1

paroxysmal
persistent
permanent
(can switch categories but once permanent cant go back)

Question 2

how does AF progress?

Answer 2

most people end up in permanent AF at some point

Question 3

most common symptoms of AF?

Answer 3

decreased exercise tolerance

lethargy and fatigue

Question 4

other symptoms of AF?

Answer 4

breathlessness
palpitations
chest pain
can be asymptomatic

Question 5

why does reduced exercise tolerance occur in AF?

Answer 5

ventricular rate is higher at rest so when exercising, instead of increasing from 70-110, it increases from 90-150

Question 6

1st management of permanent AF?

Answer 6

rate control

Question 7

rate control in AF?

Answer 7

beta blocker = first line
bisoprolol (5mg increasing to 10mg if needed)
rate limiting CCB used if beta blocker not appropriate (asthma etc)
diltiazem/verapamil
digoxin added (either BB + digoxin or CCB + digoxin) if single drug not controlling rate

Question 8

why is digoxin not used alone?

Answer 8

effects are overcome by sympathetic drive (eg in exercise etc) so not useful alone in younger people as it wont be effective anytime they are somewhat active
can be somewhat useful in elderly less mobile people but same thing will happen if they have a fall or anything causing a stress on the body
BB and CCBs block the sympathetic drive so digoxin V good in combination with digoxin

Question 9

2nd management of AF?

Answer 9

anti coagulation

Question 10

how do you determine whether to anti coagulate or not?

Answer 10

CHA2DS2VASc score
0 = dont anti-coagulate (risks outweight benefits)
1 = consider anti-coagulation (usually do it)
2 = definitely anti-coagulate

Question 11

how is gender used in CHA2DS2VASc score?

Answer 11

female only counted as 1 point if they have other risk factors
so if theyre a women but have no other risk factors then they have a score of 0
but if theyre a woman and are over 65 (which counts as 1 point) then they will get a score of 2

Question 12

how are AF patients anti-coagulated?

Answer 12

direct oral anticoagulants (DOACs)

• edoxaban (mainly)
• rivaroxiban (more for DVT and PE)
• dabigatran

Question 13

what is the goal of persistent AF management?

Answer 13

restore sinus rhythm

done via electrical (DC) or chemical cardioversion

Question 14

what drugs are used for chemical cardioversion?

Answer 14

amiodarone

flecainide

Question 15

risks of cardioversion?

Answer 15

both have equal risk of dislodging a clot just bc of sudden change of rhythm

Question 16

when can cardioversion be done?

Answer 16

if onset of AF within 12/24/48 hrs (depending on guideline)

generally dont cardiovert if >65??

Question 17

what should you do if patient has been in AF for >48 hrs?

Answer 17

anti-coagulate for 5-6 weeks and give beta blockers to help symptoms
then bring them back after 5-6 weeks and cardiovert

Question 18

how long should anti-coagulation be given after cardioversion?

Answer 18

6 months

Question 19

can you combine DC and chemical cardioversion?

Answer 19

yes

if this doesnt work its permanent AF