Atrial Fib

Question 1

when does incidence of atrial fib increase?

Answer 1

-inc risk with age

Question 2

What is the most common sustained arrhythmia in the USA?

Answer 2

-atrial fib

Question 3

What causes atrial fib?

Answer 3

• atrial enlargement (mitral valve disease; rheumatic heart disease)
• ischemia
• toxins (ETOH, anticancer Tx)
• metabolic disease (hyperthyroidism)
• hemodynamic impairment (loss of atrial kick; tachyarrhythmia)

Question 4

**Paroxysmal AF

Answer 4

• episodes may last 1-7 days (<24hrs)

- may be recurrent (2+ episodes)

Question 5

**Persistent AF

Answer 5

• not self-limited (lasts longer than 7 days)

- paroxysmal when recurrent after reversion

Question 6

**Permanent AF

Answer 6

• lasts over a year

- cardioversion either failed or not attempted

Question 7

**Lone AF

Answer 7

• no overt cardiovascular pathology
• asymptomatic
• 10-15% all AF

Question 8

Etiologies of AF

Answer 8

• HTN
• rheumatic heart disease
• valvular disease
• myocardial ischemia/infarction (CAD)
• alcoholism
• thyroid disease
• stroke

Question 9

Symptoms of atrial fib

Answer 9

• palpitations
• sx of Heart failure (SOB, PND)
• asymptomatic

Question 10

Physical exam of atrial fib

Answer 10

• irregularly irregular and NO P - WAVES
• variable intensity S1
• heart murmur (MS/MR)
• pulmonary rales/rhonchi
• portahepatic edema
• peripheral edema

Question 11

ECG of atrial fib:

Answer 11

• irregularly irregular and NO P - WAVES

- f-waves (fibrillatory waves)

Question 12

Hockey stick deformity on echo with?

Answer 12

• mitral stenosis

- atrial fib if mitral stenosis is also present

Question 13

Who has increased risk for atrial fib?

Answer 13

• Age>65yo
• HTN
• rheumatic heart disease
• previous stroke or TIA
• diabetes mellitus
• congestive HF

Question 14

AF - tx:

Answer 14

1) rhythm control - restore and maintian sinus rhythm
- improve symptoms
- improve hemodynamics
- reduce stroke risk
- avoid anticoagulation
2) rate control- maintain acceptable ventricular rate in chronic AF

Question 15

Controlling rate or rhyhtm leads to lower mortality?

Answer 15

RATE CONTROL!

Question 16

What did AFFIRM study show?

Answer 16

• rhythm control vs rate control showed no survival advantage
• stroke risk was similar between groups
• more drug adverse effects with rhythm control groups

Question 17

AF and trying to control Rhythm results in

Answer 17

a lot of adverse drug effects! (AFFIRM STUDY)

Question 18

• Suggestive approach to tx first AF event:

- Objectives of Tx:

Answer 18

1) evaluate for precipitating cause
2) clinical status determined initial Tx
3) Objectives of tx:
- Rhythm control-restore/maintain NSR
- rate control-maintain acceptable ventricular rate in chronic AF
- avoid embolic events

Question 19

What is specific tx for rhythm control:

Answer 19

1) DC conversion to NSR prefered vs drug
2) urgent DC cardioversion needed if:
- current myocardial ischemia
- evidence of hypoperfusion
- severe heart failure symptoms
- pre-excitation present
3) pHarmacologic
- NOT PRIMARY CHOICE
- AF < 1week=dofetilide - first choice if we must go this route
- AF > 1 week = dofetillide, amiodarone, ibutilide

Question 20

What is goal of tx for rate control?

Answer 20

• goal is to get HR to 80 - 110 (lenient rate control)

- avoid cardiomyopathy mediated by inc HR

Question 21

What is prefered method for controlling AF?

Answer 21

-rate control

Question 22

WHen to hospitalize AF paitent?

Answer 22

• if put on anticoags and need to monitor
• if need invasive procedure (ablasion)
• old people
• people with acute coronary syndrome
• people with other conditions such as cancer

-OTHERWISE SEND THEM HOME!

Question 23

if cardioverting patient need to ..

Answer 23

keep them on antitrombotics for 3 weeks prior, during and 4 weeks agter cardioversion

Question 24

contraindications for antithrombotics?

Answer 24

• under 60yo

- lone AF

Question 25

Most common antithrombotics for AF?

Answer 25

• heparin
• warfarin
• aspirin (+ clopidogreL)
• rivaroxaban (super expensive)

Question 26

Ablation what do they do?

Answer 26

-put catheter in heart and kill it with radiowaves –> give pacemaker then