Atrial Fibrillation

Question 1

Presentation of AF

Answer 1

Often asymptomatic but can present with:
Fast irregular HR 
dizziness
syncope
chest pain
SOB

or with symptoms of associated conditions:
strokes
thyrotoxicosis
sepsis

Question 2

Types of AF

Precipitants for AF

Answer 2

1. Valvular - moderate-severe MR or mechanical heart valve
2. Non-valvular

SMITH
S = sepsis 
M = mitral valve pathology 
I = =IHD
T = thyrotoxicosis 
H = HTN

\+
age 
surgery, sleep apnea, smoking 
alcohol 
PE 
CKD, DM, male, Obesity

Question 3

Differential for irregulary irregular pulse

Answer 3

AF
Ventricular ectopics
complete heart block with variable ventricular escape
A. Flutter

-distinguished from each other by ECG with ventricular ectopics disappearing when heart rate increases

Question 4

Investigations to enquire about

Answer 4

ECG
ETT
ECHO
Bloods - TFT, UEC, Trops

Question 5

2 principals of management

Answer 5

1. rate/rhythm control

2. anticoagulation

Question 6

Acute management:

Answer 6

1st line is rate control unless there is the following:
- < 48h since clear onset
- reversible cause
- AF is causing HF or haemodynamically unstable
- symptomatic despite being rate controlled
In which case pharm cardioversion - flecainide or amiodarone infusion or DC cardioversion (immediate or delayed) can be used to rhythm control

Rate control using

1. Bisoprolol or atenalol (not in acute HF)
2. Diltiazem
3. Digoxin (only in sedentary people and check levels as can cause N+V, neuro impacts)

Thromboprophylaxis/Anti-coagulation

• 1st line is dabigitran (or rivaroxiban)
• 2nd line is warfarin with LMWH (enoxaparin) used to bridge until warfarin is at therapeutic level (INR 2-3)

Question 7

Chronic Management:

Answer 7

1. Continued rate control
2. Rhythm control post medical or DC cardioversion either done acutely or after 3 weeks of anticoagulant
   Amiodarone = no exclusions but check TFT, LFT, PFT
   Sotalol = not if EF < 35%
   Flecainide = not if structural defect, only AF

“pill in the pocket” for PAF with flecainide or sotalol
- NOT IF A. FLUTTER

Question 8

Antiocoagulation? the decision

Answer 8

Without anticoagulation their risk is about 5% per year depending on score. With meds it drops to about 1-2% so small absolute but 2/3 relative reduction.
Puts risk of bleeds at 2-3% when on anticoagulation

CHA2DS2VAS > 1 
CHF 
HTN 
Age2 >75 
DM 
Stroke 2
Vasc disease 
Age > 65 
Sex - male