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YR6: CARDIAC > Atrial Fibrilation > Flashcards

Atrial Fibrilation Flashcards

1
Q

What is atrial fibrillation?

A

Supraventricular tachyarrhythmia resulting from irregular, disorganized electrical activity + ineffective contraction of the atria.

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2
Q

3 Patterns of AF

A

Paroxysmal AF
Persistent AF
Permanent AF

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3
Q

What is paroxysmal AF?

A

AF lasting >30s but <7 days (often <48h).
Self-terminating + recurrent.

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4
Q

What is persistent AF?

A

AF >7 days (spontaneous termination unlikely to occur after this time)
or <7 days but requiring cardioversion.

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5
Q

What is permanent AF?

A

AF that:
failed to terminate with cardioversion
OR
terminated but relapsed within 24h
OR
longstanding AF (>1y) in which cardioversion is CI or not been attempted

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6
Q

What 2 pathophysiological consequences may result due to loss of active ventricular filling?

A

Stagnation of blood in atria leading to thrombus formation + risk of embolism, increasing risk of stroke.
Reduction in CO: may lead to HF

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7
Q

Give 2 epidemiological facts on AF

A

VERY COMMON in elderly
M > F

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8
Q

What are the 4 most common causes of AF?

A

Coronary artery disease
HTN
Valvular heart disease
Thyrotoxicosis

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9
Q

What 3 lifestyle factors can cause AF?

A

Caffeine intake
Excessive alcohol intake
Obesity

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10
Q

What are 4 symptoms of AF?

A 
Often ASYMPTOMATIC 
Palpitations 
Chest pain
Dyspnoea
Syncope (if low output)
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11
Q

List 3 possible signs of AF

A

Irregularly irregular pulse
Apical pulse rate > radial pulse rate
Signs of thyroid disease/ valvular disease

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12
Q

What investigation is required to confirm diagnosis of AF?

A

ECG
+/- ambulatory ECG for paroxysmal

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13
Q

Describe an ECG in AF

A

Chaotic baseline
Absent p waves
Irregular intervals between QRS complexes

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14
Q

List the 4 life-threatening features of tachycardias

A

Shock (Hypotension)
Syncope
Signs of myocardial ischaemia
Signs of Heart failure

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15
Q

What characterises Atrial flutter?

A

SVT
Similar symptoms as AF
Saw tooth pattern on ECG

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16
Q

Once AF is identified on ECG, what investigations are performed?

A

Bloods
Echo (TTE/ TOE)

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17
Q

What investigations can be performed to aid identification of underlying cause of AF?

A

FBC (Infection, Anaemia)
U+Es (Electrolyte imbalance)
TFTs (Thyrotoxicosis)
Cardiac enzymes

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18
Q

What 4 states may be seen on echocardiogram in AF?

A

Mitral valve disease
LA dilatation
LV dysfunction
Structural abnormalities

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19
Q

What are the 3 main components of management in AF?

A

Rhythm control
Rate control
Reduce stroke risk

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20
Q

When should rhythm control be tried first line in AF?

A

Haemodynamically unstable
New onset AF <48h
Heart failure (primarily caused by AF)
Reversible cause.

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21
Q

Describe management of haemodynamically unstable patient with AF

A

DC cardioversion

22
Q

If rhythm control is indicated in a haemodynamically stable patient, describe management?

A

<48h: Heparinise + cardioversion
>48h: rate control + anti-coagulate for >,3w OR TOE to exclude a left atrial appendage thrombus then proceed

23
Q

Describe ongoing management if AF is confirmed as being less than 48h and resolved with DC cardioversion

A

Further anticoagulation unnecessary

24
Q

If onset of AF was more than 48 hours ago, why must a patient be anti-coagulated for at least 3 weeks prior to cardioversion?

A

High risk of cardioversion induced thromboembolism as clot likely to have formed in atria

25
Q

What is used in pharmacological cardioversion?

A

Structural heart disease: Amiodarone
NO structural heart disease: Flecainide

26
Q

Describe electrical cardioversion

A

Synchronised to R wave to prevent delivery of a shock during the vulnerable period of cardiac repolarisation when VF can be induced.

27
Q

What indicates high risk of cardioversion failure? How can this be mitigated?

A

Previous failure or AF recurrence
Give at least 4w amiodarone or sotalol prior to DC cardioversion

28
Q

Which drugs are used for rate control in AF?

A

B-blockers
Rate limiting CCB e.g. Diltiazem
Digoxin

29
Q

List 3 b-blockers used in AF

A

Metoprolol
Atenolol
Propanolol

30
Q

Name a common contraindication to B-blockers in AF. What should be used first line?

A

Asthma
Use CCB e.g. Diltiazem

31
Q

In which patients with should nondihydropyridine CCBs be avoided?

A

Acute decompensated HF

32
Q

Which drug is used second line for rate control in AF?

A

Digoxin

33
Q

What non-pharmacological method can be used for rate control in AF?

A

Catheter ablation
(percutaneous, via groin)
ablates faulty electrical pathways resulting in AF

34
Q

Give 3 indications for catheter ablation in AF

A

Recurrent AF
Refractory to medical rate control
If don’t tolerate drugs

35
Q

Describe the use of anticoagulation with catheter ablation

A

Anticoagulate for 4w prior + during procedure
Catheter ablation controls rhythm but doesn’t reduce stroke risk
Continue anticoagulation as per CHADSVASc

36
Q

Give 4 complications of catheter ablation for AF

A

Cardiac tamponade
Stroke
Pulmonary vein stenosis
Recurrence of AF

37
Q

What tool is used to assess and manage stroke risk in AF?

A

CHA2DS2-Vasc Score

38
Q

What are the elements of CHA2DS2VASc?

A

Congestive HF 1
HTN (inc. treated HTN) 1
Age >= 75y (2), 65-74y (1)
Diabetes 1
S2 Prior Stroke, TIA or thromboembolism 2
Vascular disease (inc. IHD + PAD) 1
Sex (F) 1

39
Q

Describe the anticoagulation strategy based on CHA2DS2VASc score

A

0: No Tx
1: M: Consider anticoagulation
F: No Tx (because score 1 only due to their gender)
>,2: Offer anticoagulation

40
Q

If CHA2DS2VASc score suggests no need for anticoagulation, what must be performed?

A

TTE
to exclude valvular heart disease
Vavular heart disease in combination with AF is an absolute indication for anticoagulation.

41
Q

On what grounds should be NOT withold anticoagulation?

A

Solely on the grounds of age + falls risk

42
Q

What scoring system is used to calculate risk of bleeding in patients with AF considering anticoagulants?

A

ORBIT
Age >75y
Anaemia: Hb <130 in M, <120 in F
Bleeding hx
Renal impairment: eGFR <60
Tx with antiplatelets

43
Q

How can you remember the ORBIT parameters?

A

Old (age)
Red cells (anaemia)
Bleeding hx
Impairment (renal)
Treatment (anti platelet Tx)

44
Q

What class of drug is used first line for anticoagulation in AF? Give 4 examples

A

DOACs
Apixaban
Dabigatran
Edoxaban
Rivaroxaban

45
Q

What drug is used for anticoagulation in AF when DOACs are contraindicated?

A

Warfarin

46
Q

What is are the main complications of AF?

A

THROMBOEMBOLISM
Worsening of existing heart failure

47
Q

What mnemonic lists the causes of AF?

A 
Dehydrated PIRATES
Dehydration
Pulmonary disease: PE
Ischaemia: HTN, HF, IHD
Rheumatic heart disease
Anaemia, Atrial myxoma
Thyrotoxicosis
Ethanol abuse
Sepsis
48
Q

What sign may you see on ECG in a patient taking digoxin?

A

Normal QRS with ‘scooped’ ST depression
aka ‘revere tick sign’

49
Q

What are the 4 categories of aetiologies of causes of ST depression with normal QRS?

A

Ischaemia
Hypokalemia
Digoxin
Normal variant

50
Q

What should be used for long term stroke prevention in patients with AF once haemorrhage has been excluded?

A

Following TIA: DOAC (or warfarin) immediately
Following acute stroke: DOAC (or warfarin) after 2w (anti-platelet in the interim)

YR6: CARDIAC (41 decks)

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