Atrial Fibrillation Flashcards
Types of Arrhythmias
Classifications of Atrial fibrillations
- Fist diagnosed - AF not diagnosed before, irrespective of its duration or the presence/severity of AF related symptoms
- Paroxysmal - AF that terminates spontaneously or with intervention within 7days of onset.
- Persistent - AF that is continuously sustained beyond 7 days, including episodes terminated by cardioversion (drugs or electrical cardioversion) after 7 or more days
- Long-standing persistent - continuous AF of more than 12months duration when decided to adopt a rhythm control strategy
- Permananent - af that is accepted by the patient + physician and not further attempts to restore/maintain sinus rhythm will be undertaken. Permannt AF represents a therapeutic attitidude of the patiwnet + physician rather than an inherent pathophysiologicla attribute of af, and term should not be used in context of rhythm contorl startegy with antiarrhythmic drug therapy or AF ablation. Should a rhythm contorl strategy be adopted, the arrhythmia would be re-classified as ‘long standing persistent AF’
causes of Atrial fibrillation
Normla sinus rhythm is
P wave spresent, regular and nromal morpholpgy (axis 0 to 75degrees)
QRS complexes are present, regular and narrow (<120ms)
1:1 ratio between p wave and QRS complex (HR 60-100bpm)
General Management of AF
for this case
- ABCDE approach - clinical evaluation, investigations, treatmen. Airway patent (snoring, gurgling, responding to voice),Breathing spontaneously, Sa02, RR, chest sounds? ABG, CXR. Oxygen via non-rebreath mask. BP, HR, perfusion, HS? bloods, IV access, ECG, bedside echo.Fluids vs. furosemide, DCCV, drugs (atropine, adenosine, adrenaline) . GCS?, BM. expose the patient, abdomen SNT?
- Invetsiagtions - ECG, CXR
- Critical care review: I&V, DNACPR
- Loaded on amiodarone 300mg IV and then 900mg IV over 24hours (via. CVC)
- DC cardioversion
- IV furosemide 40mg TDS
- GTN infusion
- Actrapid infusion
- Norad started (low BP after intubation)
If unstable, patient requires imediate DC cardioversion.
Normal vs abnormal CXR
One on left, has consolidation (mos tlikely pulmonary oedema, has big heart, pleural effusion).
HR 150 irregular
No clear P waves
Advanced ;ife suppor tfor tachycardia
management for…
64-year old male admitted with palpitations and pre-syncope, started that very morning
PMH: Alcohol excess, previous TIA, recent positive COVID19 swab
DH: Nil regular
SH: Ex-smoker, good exercise tolerance
O/E, Sa02 98% on RA, RR 19, chest: mild bilateral wheeze, HR 128, BP 133/97, HS I + II + ESM, no pitting oedema
Do ECG - the image shows irregular tachycardia. Narrow complex - atrial fibrillaytion.
Manage with: (acute, <48hours onsey)
- DC cardioversion - anaesthetic support fo rairway, can sat 50-100J and defibrillator but synchronised shock
- IV amiodarone - 300mg iV loading dose then 900mg/24hours. Large bore cannula, ideally central line.
–
- 2x failed DCCV. Loaded on amiodarone and given 24hour infusion via centrla line. Started on apizaban and bisoprosol
- 24HOURS LATER- Stil in AF but rate controlled, discharged home wit outpatient Holter monitor, echo, elective DCCV. If onset <48hours, consider chemical or electrical cardioversion.
AF management
Anticoag, better symptoms ovntorl, CV risf factrord
- DC cardioversion - anaesthetic support fo rairway, can sat 50-100J and defibrillator but synchronised shock
- IV amiodarone - 300mg iV loading dose then 900mg/24hours. Large bore cannula, ideally central line.
if rhythm contorl fails then manage –
- 2x failed DCCV. Loaded on amiodarone and given 24hour infusion via centrla line. Started on apizaban and bisoprosol
- 24HOURS LATER- Stil in AF but rate controlled, discharged home wit outpatient Holter monitor, echo, elective DCCV.
If onset <48hours, consider chemical or electrical cardioversion.
Use score for anticoagulation.
Rate vs rhythm control
Management:
- 70-year old M, admitted with 5/52 weeks worsening breathlessness and chest heaviness
- PMH: COPD
- DH: Nil regular
- SH: smoker, good exercise tolerance, recently moved back from Spain
- O/E, Sa02 97% on RA, RR 18, chest: intermittent wheeze + few crackle in L base, JVP +6, HR 132, BP 106/77, no pitting oedema
- ECG - shows tachycardia, narrow complex (less than 3 swuares), irregular, no clear p waves, so atrial fibrillation (too irregular for atrial flutter).
- Chest xR - fluid in lungs
- Coudl do rhythmy startegy with fluconoaid, give
- Anticoag
- Give bsioprosl 5ml/od, xipca 5mg nlood. foresomide 40mgf ood. Echocrdiorghrapm, penign removed rate control.
Scoring anticog=ag risk
Treat AF. ABC pathway
SYmptom contol for AF
Rhtyhm control
Assess factord favouei rhyhtm control
Rtae vs rhythm contor strat of AF
Rate vs. rhythm control
AFFIRM and RACE study: no difference
EAST AFNET study: benefits of early rhythm control
RACE II: lenient ~ strict rate-control
Compehensive AF risk fators for optimising outome of AF catheter addtion.
80-year old F with 24 hours history of intermittent pre-syncope + palpitations
PMH: Admission 1 year ago with normal echocardiogram and normal coronary angiogram, hypothyroidism
DH: bisoprolol 1.25mg od (very symptomatic at higher doses), atorvastatin 20mg at night
SH: good exercise tolerance, independent
O/E, Sa02 95% on RA, RR 18, chest: clear, JVP normal, HR 150, BP 115/90, no pitting oedema
ECG looks liek atrial fluter. Treatment startegues ar ethe smae.
- Flecamide 200mg ov e RN when symptomd cccour amd are not settling. Flecanaide s contradictae n those with exisr ibtanche s or cnry hert fidease
- Pill in pocket srat is option for heslth pstient wihi interefrequent episode od syptomatic AF
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