Atrial FIbrilation

Question 1

What is AF?

Answer 1

Where the contraction of the atria is uncoordinated, rapid and irregular. This is due to disorganised electrical activity that overrides the normal, organised activity from the SA node.

Question 2

What does AF result in?

Answer 2

Irregularly irregular ventricular contractions
Tachycardia
Heart failure due to poor filling of the ventricles during diastole
Risk of stroke
Risk of thrombus formation and stroke

Question 3

What are the presenting features of AF?

Answer 3

Palpitations
Shortness of breath
Syncope
Symptoms of associated conditions (stroke, sepsis or thyrotoxicosis)

Question 4

What are the two differential diagnoses for a irregularly irregular pulse?

Answer 4

Atrial fibrilation

Ventricular ectopics

Question 5

How does AF appear on an ECG?

Answer 5

Absent P waves
Narrow QRS complex tachycardia
Irregularly irregular ventricular rhythm

Question 6

What is the definition of valvular AF?

Answer 6

Patients with AF who also have moderate or severe mitral stenosis or a mechanical heart valve

Question 7

What are the most common causes of AF?

Answer 7

SMITH
Sepsis
Mitral valve pathology 
Ischaemic heart disease 
Thyrotoxicosis 
Hypertension

Question 8

What are the two principles of treating AF?

Answer 8

Rate or rhythm control

Anticoagulation to prevent stroke

Question 9

Rate control should be first line for AF unless….

Answer 9

There is a reversible cause
Their AF is of new onset (within 48 hours)
Their AF is causing heart failure
They remain symptomatic despite being effectively rate controlled

Question 10

What are the options for rate control?

Answer 10

Beta blocker (first line)
Calcium channel blocker (diltiaxem) (not preferable in HF)
Digoxin (only in sedentary people, needs monitoring and toxicity )

Question 11

When is immediate cardio version an option?

Answer 11

If the AF has been present for less than 48 hours or they are severely haemodynamically unstable

Question 12

What should happen before delayed cardio version?

Answer 12

The patient should be anti coagulated for 3 weeks (should be rate controlled during this time

Question 13

What drugs can be used for pharmacological cardioversion?

Answer 13

Flecainide
Amiodarone (drug of choice in patients with structural heart disease)

Question 14

Describe electrical cardioversion

Answer 14

The aim is to rapidly shock the heart into sinus rhythm. This involves sedation or a GA and using a cardiac defibultator machine.

Question 15

What drugs can be used for long term medical rhythm control?

Answer 15

Beta blockers
Dronedarone
Amiodarone (patients with HF or LVD)

Question 16

What drug can be used as a “pill in the pocket” approach to paroxysmal AF?

Answer 16

Flecanide

Question 17

What are the advantages of NOACS over warfarin?

Answer 17

No monitoring
NO major interactions
Equal or slightly better at preventing strokes in AF
Equal or slightly less risk of bleeding

Question 18

What us the target INR for SF?

Answer 18

2-3

Question 19

Describe the CHA2DS2-VASc score

Answer 19

C-congestive heart failure
H- hypertension
A2 - age >75
D - diabetes
S2 - stroke or TIA
V- Vascular disease
A -age 65-74
S - sex (female)

Question 20

What do the scores mean in the CHA2DS2-VASc score?

Answer 20

0 - no anticoagulation
1 - consider
>1 - offer

Question 21

What does HASBLED stand for?

Answer 21

Hypertension
Abnormal renal and liver function 
Stroke
Bleeding 
Labile INRs
Elderly
Drugs or alcohol