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CVS (Cardiology) > Arrhythmias - Atrial Fibrillation > Flashcards

Arrhythmias - Atrial Fibrillation Flashcards

1
Q

What is Atrial Fibrillation?

A

Unco-ordinated, rapid and irregular contraction of the atria.

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2
Q

Pathophysiology of Atrial Fibrillation.

A

Disorganised electrical activity that overrides the normal, organised activity from the Sinoatrial node.

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3
Q

Effect of Atrial Fibrillation of Ventricles (4).

A

Irregular Conduction of Electrical Impulses to Ventricles :
1. Irregularly irregular ventricular contractions.
2. Tachycardia.
3. Heart Failure (poor filling during diastole).
4. Risk of ischaemic-embolic stroke.

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4
Q

Aetiology of Atrial Fibrillation (5).

A

SMITH :
1. S - Sepsis.
2. M - Mitral Valve Disease (Rheumatic HD).
3. I - Ischaemic Heart Disease.
4. T - Thyrotoxicosis.
5. H - Hypertension.

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5
Q

What is Valvular AF?

A

Patients with AF also have moderate or severe mitral stenosis or a mechanical heart valve. Other/Absent valve disease is non-valvular AF.

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6
Q

Differential Diagnoses of Irregularly Irregular Pulse (2).

A
  1. Atrial Fibrillation.
  2. Ventricular Ectopic.
    * Use ECG to differentiate and Ectopics disappear when HR gets over certain threshold (e.g. exercise).
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7
Q

Clinical Presentation of Atrial Fibrillation (6).

A
  1. Asymptomatic & Incidental Findings.
  2. Palpitations.
  3. SOB.
  4. Syncope.
  5. Symptoms of Associated Conditions e.g. Stroke, Sepsis, Thyrotoxicosis.
  6. Irregularly Irregular Pulse.
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8
Q

ECG Findings in Atrial Fibrillation (3).

A
  1. Absence of P Waves (lack of co-ordinated atrial electrical activity).
  2. Narrow QRS Complex Tachycardia.
  3. Irregularly Irregular Ventricular Rhythm.
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9
Q

Management of Atrial Fibrillation (2).

A

2 Principles :
1. Rate/Rhythm Control.
2. Anticoagulation (Prevention of Stroke).

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10
Q

What is the rationale of Rate Control? (3)

A
  1. Atria pump blood into the ventricles but since atrial contractions are unco-ordinated, ventricles fill up by suction and gravity.
  2. A higher HR means less time is available for filling which reduces CO.
  3. By getting HR below 100, diastolic time is increased so ventricles fill with more blood.
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11
Q

Contraindications of Rate Control (4).

A
  1. Reversible Cause.
  2. New-Onset (Last 48 Hours).
  3. Co-Existent Heart Failure.
  4. Symptomatic Despite Effective Rate Control.
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12
Q

Options for Rate Control (3).

A
  1. B-Blocker 1st Line.
  2. Non-DHP CCB e.g. Dilitazem, Verapamil (not preferable in HF),
    3*. Digoxin (sedentary people, needs monitoring due to risk of toxicity).
    * Monotherapy or Dual Combination Therapy.
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13
Q

What is the principle of rhythm control?

A

Return patient to normal sinus rhythm - single ‘cardioversion’ event or long-term medical rhythm control.

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14
Q

Timings of Cardioversion (2).

A
  1. Immediate - Onset < 48 hours or haemodynamically unstable = HEPARINISE patient.
  2. Delayed - Onset > 48 hours and stable.
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15
Q

Methods of Cardioversion (2).

A
  1. Pharmacological - 1st line Flecanide (or Amiodarone if structural heart disease).
  2. Electrical (sedation/GA and cardiac defibrillator to rapidly shock the heart back into sinus rhythm).
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16
Q

Important Considerations of Delayed Cardioversion (6).

A
  1. ANTICOAGULATION 3 weeks prior to Cardioversion (clot may have formed in 48 hours).
  2. RATE CONTROL whilst waiting for Cardioversion.
  3. Alternative : TOE to exclude left atrial appendage (LAA) Thrombus) = Heparinise and Cardiovert immediately.
  4. Electrical > Pharmacological.
  5. Anticoagulation for at least 4 weeks after.
  6. If high-risk of failure e.g. recurrent, previous failure 4 weeks Amiodarone/Sotalol prior.
17
Q

Methods of Long-Term Medical Rhythm Control (3).

A
  1. B-Blockers (1st line).
  2. Dronedarone (2nd line + successful cardioversion).
  3. Amiodarone (HF or left ventricular dysfunction).
18
Q

What is the main issue with cardioversion?

A

The moment a patient switches from AF to sinus rhythm presents the highest risk for embolism (stroke).

19
Q

How is the shock synchronised in electrical cardioversion?

A

Sync to R wave to prevent delivery of a shock during the vulnerable period of cardiac repolarisation (which may induce VF).

20
Q

What scoring system is used to assess whether a patient should be started on anticoagulation if they have AF?

A

CHA2DS2-VASC Score :
1. C - Congestive HF.
2. H - HTN.
3. A - Age > 75 (2).
4. D - Diabetes.
5. S - Stroke/TIA (2).
6. V - Vascular Disease.
7. A - Age (64-75).
8. S - Female Sex.
* 0 = No Anticoagulation; 1 = Consider in Males; 2+ = Offer.

21
Q

Methods of Anticoagulation (2).

A
  1. Warfarin.
  2. NOACs.
22
Q

What investigation is still advised if CHA2DS2VASC score is 0/1?

A

TOE to exclude valvular heart disease.

23
Q

What scoring system is used to assess a patient’s risk of major bleeding whilst on anticoagulation?

A

ORBIT Tool :
1. Low Haemoglobin(<130 males or <120 females) /Haemoatocrit (<40% in males or <36% in females) = 2 Points.
2. Age 75+ = 1 Point.
3. Previous Bleeding (GI, Intracranial) = 2 Points.
4. Renal Function (GFR < 60) = 1 Point.
5. Antiplatelet Medications = 1 Point.
* 0-2 : Low; 3 : Medium; 4-7 : High.

24
Q

What scoring system was previously used instead of ORBIT?

A

HASBLED :
1. H - HTN.
2. A - Abnormal Renal/Liver Function.
3. S - Stroke.
4. B - Bleeding.
5. L - Labile INR (Warfarin).
6. E - Elderly.
7. D - Drugs/Alcohol.

25
Q

Indications of Catheter Ablation.

A

No Response to or avoidance of anti arrhythmic medication.

26
Q

Rationale of Catheter Ablation.

A

Ablate faulty electrical pathways percutaneously (via groin) -both radio frequency and cryotherapy.

27
Q

Anticoagulation with Catheter Ablation (2B).

A
  1. 4 weeks prior and during procedure.
    2A. CHA2DS2VASC 0 = 2 Months.
    2B. CHA2DS2VASC 1+ = Long-Term.
28
Q

Complications of Catheter Ablation (3).

A
  1. Cardiac Tamponade.
  2. Stroke.
  3. Pulmonary Vein Stenosis.
29
Q

What are the types of AF? (3B).

A
  1. First Detected Episode.
  2. Recurrent - 2+ Episodes.
    2A. Paroxysmal (Episode < 7 Days).
    2B. Persistent (Episode > 7 Days).
  3. Permanent (Continuous which cannot be cardioverted).
30
Q

What is Paroxysmal AF?

A

Episodic AF - not lasting more than 48 hours.

31
Q

Management of Paroxysmal AF.

A

Pill in the Pocket Approach with Flecanide.

32
Q

Why should Flecanide be avoided in Atrial Flutter?

A

It can cause 1:1 AV conduction, resulting in a significant tachycardia.

33
Q

Management of AF Post-Stroke (3).

A
  1. Warfarin/Direct Thrombin/Factor Xa Inhibitor.
  2. Commence after 2 weeks if absence of haemorrhage.
  3. Delay if very large cerebral infarction.

CVS (Cardiology) (37 decks)

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