AFIB Flashcards
ECG CRITERIA
a. Fibrillatory waves of atrial activity seen in leads V1, V2, V3, and aVf
b. Irregular ventricular response, usually 170 to 180 beats / min
c. Can be paroxysmal, persistent or chronic
Definition of New Onset, vs. Paroxysmal vs. Persistent vs. Permanent
New Onset: not previously documented
Paroxysmal: terminates spontaneously or with intervention within 7 d
Persistent: > 7 days
Permanent: lasting > 1 year
6 CARDIAC ETIOLOGY / RISK FACTORS
HTN, Valvular Disease, CAD, CHF, Cardiomyopathy, Pericarditis, Myocarditis, Sick Sinus Syndrome
6 NON-CARDIAC ETIOLOGY / RISK FACTORS
Thyrotoxicosis, Infection, COPD, OSA, PE, Obesity, Diabetes, GERD, Stress
Alcohol, Cocaine
PE Infection Rheum Alcohol and Age Trauma and Toxins and Thyroid Electrolytes Sepsis
6 SYMPTOMS
Asymptomatic Palpitations Reduced Exercise Capacity Syncope / Dizziness Heart Failure Chest Pain Dyspnea Stroke
INITIAL LABS
• CBC, Cr, Lytes, LFTs, TSH, A1c, Lipids, INR
INITIAL INVESTIGATIONS & WHY YOU WOULD DO THEM
ECG (confirm AF, assess for structural disease, risks for complications)
Echo – assess for valvular disease, atrial enlargement, systolic function
First Step in Management of Acute AFIB. Management of Afib secondary to medical cause
Determine if the Afib is primary, or secondary to a medical cause
Investigate and treat underlying causes aggressively
Cardioversion may be harmful
Avoid rate control
Clinical Features and ED MANAGEMENT OF THE ACUTE UNSTABLE PATIENT
Altered Mentation
Hypotension – sBP <90 OR a drop of 30% from their baseline
Cardiac Ischemia / Angina
Decompensated Heart Failure
Synchronized cardioversion (150 to 200 J) if onset < 48 hrs or WPW
Consider trial of rate control
DEFINITION OF THE STABLE HIGH RISK (for clot) PATIENT (CAEP GUIDELINES)
- No therapeutic OAC > 3 weeks AND
- Onset > 48 hrs OR unknown OR
- Stroke/TIA <6 months OR
- Mechanical or Rheumatic Valve
ED MANAGEMENT OF THE ACUTE STABLE HIGH RISK (for clot) PATIENT (CAEP GUIDELINES)
- Rate control to <100
- Discharge on OAC x 3 weeks
- TEE to exclude thrombus then Cardioversion
DEFINITION OF THE STABLE LOW RISK PATIENT (CAEP GUIDELINES)
- Clear onset <48 hrs with no high-risk factors OR
* Therapeutic OAC > 3 weeks
ED MANAGEMENT OF THE ACUTE STABLE LOW RISK PATIENT (CAEP GUIDELINES)
Rhythm Control Preferable: either pharm or electrical
Rate control acceptable
Immediate Anticoagulation in ED not required
Shock and then start on anticoagulation and refer
Higher rate of success if within 48 hours
Shock and send home, short ED stay
POST CARDIOVERSION MANAGMENT: how do you determine the need for anticoagulation and how long do you keep them on?
Determine need of anticoagulation using CHADS-65
If >/65 or CHADS2 +ve, start NOAC
Anti-coagulate for at least 4 weeks
CHADS-65 Criteria
If > 65 -> NOAC
If >/1 point for CHADS2 -> NOAC:
If < 1 -> Antiplatelet
CHF HTN Age >65 Diabetes Stroke
Next step in management if 1. CHADS positive, if 2. CHADS negative, with stable CAD or arterial disease or 3. if CHADS negative with no CAD
- Start OCA
- Start ASA
- No Antithrombotic
First Line treatment for anticoagulation. Give 3 examples.
NOAC
Dabigatran, Apixaban, Edoxaban
Second line treatment (for stroke prevention) and give indications
Warfarin
Valvular Afib (mechanical prosthetic valve, rheumatic mitral stenosis and moderate - severe non-rheumatic mitral stenosis)
eFGR < 30
Anticoagulation if they decline OAC
ASA + Clopidogrel
Anticoagulation if they decline OAC
ASA + Clopidogrel
Contraindication to NOAC
CrCL < 30
What is preferred for maintenance: rate or rhythm control?
Rate control
4 Situations where rhythm control preferred?
Highly symptomatic
Multiple recurrences
Extreme impairment of quality of life
arrhythmia induced cardiomyopathy
First line rate control medications
Beta blocker
Non dihhydropyridine calcium channel blocker
C/i to ccb
Acute heart failure or LV dysfunction
First line rhythm control
Dronedarone
Flecainide
Propafenone (Rhythmol)
When is Amiodarone indicated for rhythm control
Abnormal VF or CHF
What is a HAS BLED score
HTN Abnormal liver or renal function Stroke Bleeding Labile INR Elderly (>65) Drugs or alcohol
List 5 non pharm managment steps
Review safety concerns (light headed, driving etc)
Follow up: Constantly reassess risks for bleeding and anticoagulation
Quit smoking
Quit drinking alcohol
Refer to cardiology
