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Year 6 Cardiology > Arrythmias: Atrial Fibrillation > Flashcards

Arrythmias: Atrial Fibrillation Flashcards

1
Q

What is atrial fibrillation (AF)?

A

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, present in around 5% of patients over aged 70-75 years and 10% of patients aged 80-85 years.

characterised by disorganised electrical activity in the atria, leading to ineffective atrial contraction and an irregularly irregular ventricular response.

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2
Q

What are the main management goals for patients with AF?

A

The most important aspect of managing patients with AF is reducing the increased risk of stroke.

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3
Q

How is AF classified?

A

AF may be classified as first detected episode, paroxysmal, persistent, or permanent.

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4
Q

What is paroxysmal AF?

A

Paroxysmal AF refers to episodes that terminate spontaneously and last less than 7 days, typically less than 24 hours.

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5
Q

What are the symptoms of AF?

A

Symptoms include palpitations, dyspnoea, and chest pain.

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6
Q

What is a key sign of AF?

A

An irregularly irregular pulse is a key sign of AF.

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7
Q

What is essential for diagnosing AF?

A

An ECG is essential to make the diagnosis of AF.

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8
Q

What are the two key parts of managing AF?

A

The two key parts of managing patients with AF are rate/rhythm control and reducing stroke risk.

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9
Q

What is rate control in AF management?

A

Rate control involves accepting an irregular pulse while slowing the rate to avoid negative effects on cardiac function.

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10
Q

What is rhythm control in AF management?

A

Rhythm control aims to restore and maintain normal sinus rhythm, which may involve pharmacological or electrical cardioversion.

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11
Q

What is the CHA2DS2-VASc score used for?

A

The CHA2DS2-VASc score is used to determine the most appropriate anticoagulation strategy based on stroke risk.

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12
Q

What anticoagulation strategy is suggested for a CHA2DS2-VASc score of 0?

A

No treatment is suggested for a CHA2DS2-VASc score of 0.

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13
Q

What anticoagulation strategy is suggested for a CHA2DS2-VASc score of 1?

A

For a score of 1, males should consider anticoagulation, while females should not receive treatment.

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14
Q

What anticoagulation strategy is suggested for a CHA2DS2-VASc score of 2 or more?

A

For a score of 2 or more, anticoagulation should be offered.

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15
Q

What are the first-line medications for rate control in AF?

A

A beta-blocker or a rate-limiting calcium channel blocker (e.g., diltiazem) is used first-line for rate control.

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16
Q

What must be considered before cardioversion in AF?

A

Patients must have had a short duration of symptoms (less than 48 hours) or be anticoagulated prior to attempting cardioversion due to the risk of embolism.

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17
Q

What did NICE update in 2021 regarding atrial fibrillation?

A

NICE updated their guidelines on the management of atrial fibrillation (AF).

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18
Q

Who should be assessed for anticoagulation in atrial fibrillation?

A

Patients with any history of AF, including symptomatic or asymptomatic paroxysmal, persistent or permanent AF, atrial flutter, and those with a continuing risk of arrhythmia recurrence.

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19
Q

What scoring system does NICE suggest for determining anticoagulation strategy?

A

NICE suggests using the CHA2DS2-VASc score.

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20
Q

What score indicates no need for anticoagulation?

A

A CHA2DS2-VASc score of 0 indicates no treatment is needed.

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21
Q

What is the anticoagulation recommendation for a CHA2DS2-VASc score of 1?

A

Males: Consider anticoagulation; Females: No treatment.

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22
Q

What should be done if the CHA2DS2-VASc score suggests no anticoagulation?

A

Ensure a transthoracic echocardiogram has been done to exclude valvular heart disease.

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23
Q

What scoring system does NICE recommend for assessing bleeding risk?

A

NICE recommends using the ORBIT scoring system.

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24
Q

What is the ORBIT score range for low bleeding risk?

A

An ORBIT score of 0-2 indicates low bleeding risk.

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25
Q

What anticoagulant was traditionally used for atrial fibrillation?

A

Warfarin was the anticoagulant of choice for many years.

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26
Q

What are the recommended direct oral anticoagulants (DOACs) for AF?

A

Apixaban, dabigatran, edoxaban, and rivaroxaban are recommended DOACs.

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27
Q

When is warfarin used in the management of AF?

A

Warfarin is used second-line in patients where a DOAC is contraindicated or not tolerated.

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28
Q

Is aspirin recommended for reducing stroke risk in patients with AF?

A

Aspirin is not recommended for reducing stroke risk in patients with AF.

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29
Q

What are the two scenarios where cardioversion may be used in atrial fibrillation?

A
  1. Electrical cardioversion as an emergency for haemodynamically unstable patients. 2. Electrical or pharmacological cardioversion as an elective procedure for rhythm control.
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30
Q

How is electrical cardioversion synchronized?

A

Electrical cardioversion is synchronized to the R wave to prevent shock delivery during the vulnerable period of cardiac repolarisation.

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31
Q

What does the NICE guideline recommend for onset of arrhythmia less than 48 hours?

A

Offer rate or rhythm control if the onset of the arrhythmia is less than 48 hours, and start rate control if it is more than 48 hours or uncertain.

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32
Q

What should be done if atrial fibrillation onset is less than 48 hours?

A

Patients should be heparinised. Those with risk factors for ischaemic stroke should receive lifelong oral anticoagulation. Cardioverting options include electrical (DC cardioversion) or pharmacology (amiodarone, flecainide).

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33
Q

What is the anticoagulation requirement for patients with AF onset greater than 48 hours?

A

Anticoagulation should be given for at least 3 weeks prior to cardioversion.

34
Q

What alternative strategy can be used for patients with AF onset greater than 48 hours?

A

Perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded, patients may be heparinised and cardioverted immediately.

35
Q

What does NICE recommend for cardioversion in patients with AF onset greater than 48 hours?

A

NICE recommends electrical cardioversion rather than pharmacological.

36
Q

What should be done if there is a high risk of cardioversion failure?

A

It is recommended to have at least 4 weeks of amiodarone or sotalol prior to electrical cardioversion.

37
Q

What is the anticoagulation requirement following electrical cardioversion?

A

Patients should be anticoagulated for at least 4 weeks after electrical cardioversion.

38
Q

What is the purpose of the 2012 guidelines by AHA, ACC, and ESC?

A

To simplify and clarify the classification of atrial fibrillation (AF).

39
Q

How many patterns is AF classified into according to the guidelines?

A

AF is classified into 3 patterns.

40
Q

What is the first pattern of AF classification?

A

First detected episode (irrespective of whether it is symptomatic or self-terminating).

41
Q

What defines recurrent episodes of AF?

A

When a patient has 2 or more episodes of AF.

42
Q

What is paroxysmal AF?

A

Episodes of AF that terminate spontaneously and last less than 7 days (typically < 24 hours).

43
Q

What is persistent AF?

A

AF that is not self-terminating and usually lasts greater than 7 days.

44
Q

What is permanent AF?

A

Continuous atrial fibrillation which cannot be cardioverted or if attempts to do so are deemed inappropriate.

45
Q

What are the treatment goals for permanent AF?

A

Rate control and anticoagulation if appropriate.

46
Q

What is atrial fibrillation (AF)?

A

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with 800,000 cases in the UK, many undiagnosed.

47
Q

What are the features of atrial fibrillation?

A

AF may present with palpitations, dyspnoea, dizziness/syncope; many cases are asymptomatic and found incidentally. The pulse is irregularly irregular.

48
Q

How is atrial fibrillation diagnosed?

A

Diagnosis is made via ECG showing absent P waves. A 24-hour ECG or event recorder is useful for suspected paroxysmal AF. Echocardiography is not required in all cases.

49
Q

What are the key elements to managing atrial fibrillation?

A
  1. Reducing the risk of stroke 2. Controlling the heart rate.
50
Q

How is stroke risk assessed in atrial fibrillation?

A

Stroke risk is assessed using the CHA2DS2-VASC scoring system to determine the need for anticoagulation.

51
Q

What is the traditional anticoagulant of choice for AF?

A

Warfarin is the traditional anticoagulant of choice, but Non-Vitamin K Antagonist Oral Anticoagulants (NOACs) have been developed as alternatives.

52
Q

What are the advantages of NOACs over warfarin?

A

NOACs do not require regular monitoring like warfarin, making them more convenient for patients.

53
Q

What are the options for controlling heart rate in AF?

A

Options include restoring normal sinus rhythm or accepting an irregular rhythm but slowing it down to reduce adverse effects of persistent tachycardia.

54
Q

What is the common management strategy for AF?

A

The majority of patients are managed with a rhythm control strategy, as they often revert back to AF after restoration of sinus rhythm.

55
Q

What medications are used to control heart rate in AF?

A

Beta-blockers and calcium channel blockers are used to control the rate, with digoxin as a second-line option.

56
Q

What methods can be used for rhythm control in AF?

A

Rhythm control can be achieved using pharmacological cardioversion, electrical cardioversion, or catheter ablation.

57
Q

What are the guidelines for managing atrial fibrillation (AF)?

A

NICE published guidelines in 2014, based on the joint AHA, ACC, and ESC 2016 guidelines.

58
Q

What agents have proven efficacy in the pharmacological cardioversion of atrial fibrillation?

A

Amiodarone and flecainide (if no structural heart disease) are agents with proven efficacy.

Other less commonly used agents in the UK include quinidine, dofetilide, ibutilide, and propafenone.

59
Q

What are considered less effective agents for atrial fibrillation?

A

Less effective agents include beta-blockers (including sotalol), calcium channel blockers, digoxin, disopyramide, and procainamide.

60
Q

What is atrial fibrillation in relation to stroke?

A

Atrial fibrillation is one of the key risk factors for ischaemic stroke.

61
Q

Why is it important to recognize atrial fibrillation post-stroke?

A

It is important to recognize and treat atrial fibrillation if identified in a patient following a stroke or transient ischaemic attack (TIA).

62
Q

What should be excluded before starting anticoagulation or antiplatelet therapy?

A

It is important to exclude a haemorrhage before starting any anticoagulation or antiplatelet therapy.

63
Q

What does NICE recommend for long-term stroke prevention in atrial fibrillation?

A

NICE recommends warfarin or a direct thrombin or factor Xa inhibitor for long-term stroke prevention.

64
Q

When should anticoagulation for AF start after a TIA?

A

Anticoagulation for AF should start immediately once imaging has excluded haemorrhage following a TIA.

65
Q

When should anticoagulation therapy be commenced in acute stroke patients?

A

In acute stroke patients, anticoagulation therapy should be commenced after 2 weeks in the absence of haemorrhage.

66
Q

What therapy should be given in the intervening period before anticoagulation in acute stroke patients?

A

Antiplatelet therapy should be given in the intervening period before anticoagulation.

67
Q

When should the initiation of anticoagulation be delayed?

A

The initiation of anticoagulation should be delayed if imaging shows a very large cerebral infarction.

68
Q

What are the NICE guidelines on the management of atrial fibrillation (AF)?

A

NICE updated its guidelines on the management of atrial fibrillation (AF) in 2021, based on the joint AHA, ACC, and ESC 2012 guidelines.

69
Q

What should be done for patients with signs of haemodynamic instability presenting with AF?

A

They should be electrically cardioverted, as per the peri-arrest tachycardia guidelines.

70
Q

How is the management of haemodynamically stable patients with AF determined?

A

Management depends on how acute the AF is:
- < 48 hours: rate or rhythm control
- ≥ 48 hours or uncertain: rate control

If considered for long-term rhythm control, delay cardioversion until maintained on therapeutic anticoagulation for a minimum of 3 weeks.

71
Q

What is the first-line treatment strategy for atrial fibrillation?

A

Rate control should be offered as the first-line treatment strategy for atrial fibrillation, except in specific cases.

72
Q

In which cases is rate control not the first-line treatment for AF?

A

Rate control is not first-line in patients with:
- Reversible causes of AF
- Heart failure primarily caused by AF
- New-onset AF (< 48 hours)
- Atrial flutter suitable for ablation
- Clinical judgement favors rhythm-control strategy.

73
Q

What agents are used for rate control in atrial fibrillation?

A

Agents include beta-blockers, calcium channel blockers, and digoxin.

Beta-blockers have a common contraindication of asthma.

74
Q

What is the role of digoxin in rate control for AF?

A

Digoxin is not considered first-line due to less effectiveness during exercise and should only be used if the person does little physical exercise or other options are ruled out due to comorbidities.

75
Q

What agents are used to maintain sinus rhythm in patients with a history of AF?

A

Agents include beta-blockers, dronedarone (second-line after cardioversion), and amiodarone (especially if coexisting heart failure).

76
Q

What does NICE recommend regarding catheter ablation for AF?

A

NICE recommends catheter ablation for patients with AF who have not responded to or wish to avoid antiarrhythmic medication.

77
Q

What is the aim of catheter ablation in AF treatment?

A

The aim is to ablate faulty electrical pathways causing AF, typically due to aberrant electrical activity between the pulmonary veins and left atrium.

78
Q

How is catheter ablation performed?

A

The procedure is performed percutaneously, typically via the groin, using either radiofrequency or cryotherapy.

79
Q

What is the anticoagulation protocol for catheter ablation?

A

Anticoagulation should be used 4 weeks before and during the procedure. It is important to remember that catheter ablation controls rhythm but does not reduce stroke risk.

80
Q

What are the recommendations for anticoagulation based on CHA2DS2-VASc score?

A

If score = 0: 2 months anticoagulation recommended. If score > 1: long-term anticoagulation recommended.

81
Q

What are notable complications of catheter ablation?

A

Notable complications include cardiac tamponade, stroke, and pulmonary vein stenosis.

82
Q

What is the success rate of catheter ablation for AF?

A

Around 50% of patients experience early recurrence of AF within 3 months, which often resolves spontaneously. After 3 years, about 55% of patients who’ve had a single procedure remain in sinus rhythm, and around 80% of those who’ve undergone multiple procedures are in sinus rhythm.

Year 6 Cardiology (36 decks)

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