Atrial fibrillation

Question 1

Symptoms and signs of AF?

Answer 1

Palpitations
Dyspnoea
Chest pain

Irregularly irregular pulse

Question 2

Ix for AF

Answer 2

ECG to rule out other causes of an irregular pulse eg ectopics or sinus arrhythmia

Question 3

When do we do rhythm control for AF?

Answer 3

Coexistent heart failure
First onset AF
An obvious reversible cause

Question 4

Rate control in AF

Answer 4

BB
Rate limiting ca channel blocker eg diltiazem

Can combine w digoxin if ineffective

Question 5

Biggest concern for people w AF

Answer 5

Stroke risk

Question 6

Causes of AF

Answer 6

mrs SMITH
Sepsis
Mitral valve pathology (stenosis or regurg)
Ischaemic heart dx
Thyrotoxicosis
Hypertension

Question 7

2 types of cardio version and when they are used

Answer 7

Immediate cardioversion- if AF has been present <48 hours or unstable
Delayed cardioversion- AF present >48 hours and stable

Question 8

If cardioversion is delated, what do we need to do in prep?

Answer 8

Minumum 3 weeks of anticoagulation

Question 9

Pharmacological cardioversion

Answer 9

Felcanide
Amiodarone (for patients w structural heart dx)

Question 10

Electrical cardioversion

Answer 10

Sedation or GA

Use a defibrillator

Question 11

What is the drug of choice for rate control in heart failure patients?

Answer 11

Digoxin

Question 12

How does digoxin work?

Answer 12

Decreases conduction through the atrioventricular node which slows the ventricular rate in atrial fibrillation and flutter

increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump. Also stimulates vagus nerve

Question 13

Digoxin toxicity features

Answer 13

Lethargy, N + V, anorexia, confusion, yellow-green vision, arrhythmia, gynaecomastia

Hypokaelmia

Question 14

Digoxin toxicity management

Answer 14

Digibind, correct arrhythmia and monitor K

Question 15

Long term rhythm control

Answer 15

BB
Dronedarone
Amiodarone

Question 16

Paroxysmal AF

Answer 16

Comes and goes, usually not lasting >48 hours

Pill in the pocket approach (flecanide)

Question 17

Anticoagulation in AF scoring system?

Answer 17

CHADSVASc

Question 18

CHADSVASc score

Answer 18

Congestive heart failure
HTN
Age > 75 (2 points) or 65-74 (1 point)
Diabetes
Stroke, TIA or thromboembolism (2 points)
Vascular dx 
Sex (female)

Question 19

Interpretation of chadsvascs

Answer 19

0- no treatment
1- males–> consider anticoagulation, female–> no treatment

2 or more–> anticoagulation

Question 20

In AF, if the chadsvasc score suggests no need for anticoagulant, what test must we do?

Answer 20

Transthoracic echocardiogram to exclude valvular heart dx

This is an absolute indication for anticoagulation

Question 21

Anticoagulation in AF, 1st and second line?

Answer 21

1st line= DOACs eg apixaban, dabigatran, rivaroxaban

2nd line= warfarin

Question 22

How many times a day do you take apixaban/dabigatran vs rivaroxaban?

Answer 22

2x vs once

Question 23

Reversal agent for apixaban and rivaroxaban?

Answer 23

Andexanet alfa

Question 24

Reversal agent for dabigatran?

Answer 24

Idarucizumab

Question 25

Pros of DOACs over warfarin

Answer 25

No monitoring
No major interaction
Equal/slightly better at preventing strokes
Equal or slightly less risk of bleeding

Question 26

Factors favouring rate control in AF?

Answer 26

Older than 65

Hx of ischaemic heart dx

Question 27

Factors favouring rhythm control in AF?

Answer 27

<65
Symptomatic
1st presentation
Lone AF or AF secondary to a corrected precipitant
CHF

Question 28

Catheter ablation

Answer 28

Used in those who have not responded to antiarrhythmic medication

Need anticoagulation 4 weeks before and during