Atrial fibrillation

Question 1

What does AF result in

Answer 1

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

Question 2

Presenting symptoms of AF

Answer 2

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

Question 3

What are the two main differentials for an irregularly irregular pulse

Answer 3

AF

Ventricular ectopics

Question 4

How can AF be differentiated from ventricular ectopics

Answer 4

ECG
Ventricular ectopics disappear when the heart rate gets over a certain threshold, therefore, a regular heart rate during exercise suggests a diagnosis of ventricular ectopics

Question 5

Features of AF on an ECG

Answer 5

Absent P waves
Narrow QRS complex tachycardia
Irregularly irregular ventricular rhythm

Question 6

valvular AF definition

Answer 6

Defined as AF with moderate or severe mitral stenosis or a mechanical heart valve

AF without valve pathologyy or with other valve pathology such as mitral regurgitation or aortic stenosis is classed as non-valvular AF

Question 7

Most common causes of AF (mrs SMITH)

Answer 7

Sepsis
Mitral valve pathology 
Ischaemic heart disease 
Thyrotoxicosis 
Hypertension

Question 8

Which patients should have rhythm control as first line

Answer 8

Reversible cause for AF
AF is of new onset(<48 hrs)
AF is causing heart failure
Remain symptomatic despite being effectively rate controlled

Question 9

Options for rate control in AF

Answer 9

Beta blocker is first line(atenolol)
Ca2+ blocker(diltiazem)(not preferable in heart failure)
Digoxin(only in sedentary people)

Question 10

When should immediate cardioversion be considered for rhythm control

Answer 10

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

Question 11

When should delayed cardioversion be considered for rhythm control

Answer 11

If AF has been present for more than 48 hrs and they are stable

Question 12

What should patients undergo prior to delayed cardioversion

Answer 12

Anticoagulation for a minimum of 3 weeks prior to cardioversion

Question 13

Options for pharmacological cardioversion

Answer 13

Flecanide 
Amiodarone(if patient has structural heart disease)

Question 14

Features of electrical cardioversion

Answer 14

involves sedation or a general anaesthetic and a cardiac defibrillator to deliver controlled chocks in an attempt to restore

Question 15

Options for long term medical rhythm control

Answer 15

Beta blockers for first line
Dronedarone 2nd line
Amiodarone in patients with heart failure or left ventricular dysfunction

Question 16

What is paroxysmal AF

Answer 16

When the AF comes and goes in episodes, usually not lasting more than 48 hrs

Question 17

Management of paroxysmal AF

Answer 17

May be appropriate for pill in pocket approach if no underlying structural heart disease

Flecanide(avoid in atrial flutter as it can cause significant tachycardia)

Anticoagulation based on CHADVASc score

Question 18

CHA2DS2VASc mnemonic

Answer 18

Congestive heart failure 
Hypertension 
A2 - Age > 75 (scores 2) 
D - Diabetes 
S2 - Stroke or TIA previously(scores 2) 
V - Vascular disease 
A - Age 65-74 
S - Sex (female)

Question 19

Interpretation of CH2DS2-VASc score

Answer 19

0: no anticoagulation
1: consider anticoagulation
>1: offer anticoagulation