Arrhythmia- Atrial fibrillation and SVT

Question 1

differentials for Regular Narrow COmplex Tachycardia with short and long RP interval

Answer 1

short RP
- AVNRT
- AVRT (orthodromic)
- focal AT with 1st degree AV block

Question 2

diagnosis?

Answer 2

AVNRT

Question 2

ECG findings for WPW pattern?

Answer 2

• short OR interval
• Prolonged QRS
• delta wave

Question 3

Arrhythmias associated with WPW syndrome?

Answer 3

Orthrodromic avrt
antidromic avrt
Atrial fibrillation - irregular wide complex tachycardia

Question 3

diagnosis?

Answer 3

atrial fibrillation

Question 4

Typical atrial flutter, ecg findings?

Answer 4

• positive in V1
• negative p wave in inferior wall

***dependent on Cavotricuspid isthmus

Question 5

Atypical Atrial flutter, ecg findings

Answer 5

positive P waves on both V1 and inferior leads

***clues: more likely in prior cardiac surgery/ablation or radiation

Question 6

Beta blockers vs CCB. which are more effective for MFAT?

Answer 6

CCB

Question 7

what are the stages of Atrial Fibrillation?

Answer 7

Stage 1 - At risk for Afib
Stage 2 - Pre-Afib
Stage 3 - Atrial fibrillation
A - Paroxysmal
B - Persistent
C - Longstanding Persistent
D - Successful Afib Ablation
Stage 4 - Permanent Afib

Question 8

Mechanism of Atrial fibrillation

Answer 8

atrial cardiomyopathy cause by atrial remodeling from both electrophysiologic and anatomic changes

Question 9

component of CHA2DS2-VA

Answer 9

C - CHF
H- Hypertension
A2 - age of ≥75
D - DM
S2 - stroke prior
V - Vascular disease
A- Age 65-74

2 or more -> oral anticoagulation is recommended
1 -> oral anticoagulation should be consider

Question 10

factors that increases the risk for Stroke that is not included in CHA2DS2-VASc

Answer 10

consider oral anticoagulation

Question 11

Question?

Answer 11

continue based on stroke risk score

Question 11

in patient with Afib, Cardiac conditions that needs to give oral anticoagulation regardless of CHA2DS2-VASc score.

Answer 11

-moderate to severe MS
- mechanical valve
- HCM
- Cardiac amyloidosis

Question 11

Anticoagulation and Typical Atrial flutter

should you continue anticoagulation after successful ablation?

Answer 11

YES, if they have previously detected AFib

Question 12

Mechanism of action of DOAC

Answer 12

“xaban” inhibits Xa
Dabigatran inhibits Thrombin

Question 13

Clinical trials associated with DOAC

Answer 13

RE-LY - Dabigatran
ROCKET-AF - Rivaroxaban
ARISTOTLE - Apixaban
ENGAGE AF - Edoxaban

Question 14

renally excreted DOAC

Answer 14

Dabigatran - 80%
Rivaroxaban - 2/3
Edoxaban -35%

APIXABAN - 25% only

Question 15

Criteria for dose adjustment for Apixaban?

Answer 15

2 of 3
- Age ≥80
- Weight ≤60
Crea ≥1.5 or 137

Question 16

Criteria for dose adjustment for Edoxaban?

Answer 16

if weight is ≤60kg, or
concomitant use of P-glycoprotein inhibitor

Question 17

Level of recommendation for using apixaban for eGFR <15 or dialysis

Answer 17

Class IIb

Question 18

reversal agent for DOAC

Answer 18

see pic

Question 19

AF complication ACS or PCI

how long do you need to put the patient on triple anti therapy after PCI

Answer 19

1-4 weeks then continue OAC+P2Y12 inhibitor

Question 19

Duration of anticoagulation after cardioversion

Answer 19

≥4 weeks

***after 4 weeks, you recheck the stroke risk if anticoagulation is still indicated.

Question 20

When to use percutaneous LAA occlusion?

Answer 20

CLASS IIa - if Afib + CHA2DS2-VASc of ≥2 + contraindication for long term oral anticoagulation

Question 21

T/F. i Afib, 90% of thrombus is located in the LAA.

Answer 21

TRUE

Question 22

most impactful lifestyle and risk factor modification in patient with atrial fibrillation

Answer 22

- Weight loss - Physical activity

Question 23

Class I lifestyle and risk factor modification in Afib, except

Answer 23

- Sleep apnea- IIB - Caffeine abstention - CLASS III

Question 24

Afib trial that shows no benefit between rate control and rhythm control

Answer 24

AFFIRM trial

Question 25

Afib ablation in HFrEF as class I indication is based on what trial

Answer 25

CASTLE-AF

Question 26

Trial: Early rhythm control therapy in patients with atrial fib showed reduction in mortality and hospitalization

Answer 26

EAST-AFNET 4

Question 27

Patient will benefit more with rhythm control with atrial fib

Answer 27

- more symptoms - LV dysfunction - new onset <1yr - AV valve regurgitation

Question 28

Class I indication for Afib ablation

Answer 28

those with reduced EF + high burden of AF in ESC 2024 - AF + HFrEF with high probability of tachycardia-induced cardiomyopathy - intolerant to antiarrhythmic drugs - as a first line option within shared decision-making control strategy to reduce symptoms, recurrence and progression

Question 29

Pre-excited Afib, which antiarrhythmic drugs to use?

Answer 29

IV procainamide IV ibutilide

Question 30

target HR for Afib. When to pursue strick HR control

Answer 30

- HF - tachycardia mediated cardiomyopathy - Symptoms with lenient HR control - Risk on inappropriate ICD shock - CRT to Bi-V pacing

Question 31

Pill in the pocket approach. which drugs are use in this approach?

Answer 31

Flecainide 200-300mg PO Propafenone 450-600mg PO

Question 32

Drugs use for pharmacological cardioversion in afib with normal LVEF, no structural disease and no prev MI

Answer 32

- Dofetilide - Dronedarone - Flecainide - Propafenone -amiodarone - sotalol - CLASS IIb

Question 33

Drugs to avoid for pharmacological cardioversion in afib with low LVEF or with structural disease

Answer 33

Flecainide propafenone dronedarone if class III or IV or had ADHF for the past 4 weeks

Question 34

Trial. Ablation vs Drug therapy that shows catheter ablation has fewer recurrent afib

Answer 34

CABANA trial

Question 35

Class I for catheter ablation for symptomatic AFIB

Answer 35

- failed AAD - young and fewer comorbidities - atrial flutter

Question 36

Class recommendation catheter ablation for Asymptomatic AFIB

Answer 36

Class IIb

Question 36

Class recommendation for surgical MAZE

Answer 36

Class IIa

Question 36

Class of recommendation for AF ablation in HF

Answer 36

for HFrEF - Class I

Question 37

Medications to avoid in HCM with afib

Answer 37

Flecainide and Propafenone

Question 38

recommendation for post-cardiac surgery Afib

Answer 38

no difference in mortality if rate or rhythm control

Question 39

surgical procedure that prevents afib after cardiac surgery

Answer 39

posterior left pericardiotomy

Question 40

Complication of Afib catheter ablation,atrial-esophageal fistula typically occurs during what period?

Answer 40

2-4 weeks post ablation

Question 41

when not to use adenosine?

Answer 41

patient with pre excited AFib

Question 42

among asymptomatic pt with WPW pattern, which findings are considered as low risk?

Answer 42

- abrupt loss of preexcitation on EST - Intermittent loss of preexcitation on Holter

Question 43

which of the following management of comorbidities in afib has class IIb recommendations?

Answer 43

- Mgt of OSA