Atrial Fibrillation

Question 1

What is AF?

Answer 1

contraction of the atria in a rapid, uncoordinated and irregular manner due to disorganised electrical activity overriding the normal activity.

Question 2

What can AF result in?

Answer 2

Tachycardia, irregularly irregular ventricle contractions, heart failure due to poor filling of the ventricles during diastole and risk of stroke.

Question 3

Presentation of AF?

Answer 3

Asymptomatic, palpitation, sob, syncope, associated symptoms stroke, sepsis and thyrotoxicosis

Question 4

what are the 2 diagnoses for irregularly irregular pulse?

Answer 4

atrial fibrillation and ventricular ectopics, VE disappear when the heart goes above a certain rate.

Question 5

AF on ECG?

Answer 5

absent p waves, narrow QRS complex tachycardia, irregularly irregular ventricle rhythm

Question 6

what is valvular AF?

Answer 6

Af with moderate or severe mitral stenosis or mechanical heart valve, assumption is that the valvular pathology has caused AF.

Question 7

Non-valvular AF?

Answer 7

without valvular pathology or different pathology i.e mitral regurgitation or aortic stenosis.

Question 8

causes of AF?

Answer 8

SMITH
sepsis
mitral valve pethology
ischaemic heart Disease
Thyrotoxicosis
hypertension

Question 9

principles of treating AF?

Answer 9

rate/rhythm control
anticoagulation

Question 10

why do you need to rate control?

Answer 10

lowering the heart rate increases the time for ventricle to fill with blood and increase cardiac output

Question 11

Nice suggest everyone with AF should have rate control unless:

Answer 11

remain symptomatic despite being effectively rate controlled
new onset AF (48h)
reversible cause of AF
Af is causing heart failure

Question 12

Rate control options?

Answer 12

beta blocker atenelol 50-100mg
calcium channel blocker diltiazem/verapmil (not preferred in heart failure)
digoxin (sedentary life/risk of toxicity)

Question 13

who is rhythm controlled offered to?

Answer 13

symptomatic despite effective rate controlled
new onset AF
AF causes heart failure
AF due to a reversible cause

Question 14

how to rhythm control?

Answer 14

1 time cardioversion or rhythm control meds

Question 15

difference between immediate and delayed cardioversion?

Answer 15

immediate: haemodynamically unstable or AF less than 48 hours onset
delayed: more than 48 hours AF and stable

Question 16

in delayed cardioversion what should be given?

Answer 16

anticoagulant 3 weeks prior in case of emboli and rate control meds

Question 17

difference between pharmacological and electrical cardioversion?

Answer 17

pharmacological- flecanide/ amiodarone (patients with structural heart disease)
electrical- sedation or a general anaesthetic and cardiac defibrillator

Question 18

long term medical rhythm control?

Answer 18

beta blockers first line
dronedarone second line when patient have had successful cardioversion
amiodarone in patients with heart failure or left ventricular dysfunction

Question 19

what is paroxysmal AF?

Answer 19

comes and goes not more than 48 hours, patients should still be anticoagulated

Question 20

what is pill in a pocket?

Answer 20

flecanide for AF infrequent episodes without underlying structural heart disease

Question 21

when to avoid flecanide?

Answer 21

in atrial flutter because it causes 1:1 AV conduction resulting in tachycardia

Question 22

where does blood stagnate?

Answer 22

atrial appendage

Question 23

anticoagulation reduces the risk of a stroke by?

Answer 23

2/3

Question 24

how does warfarin work?

Answer 24

blocks viatmin K and therefore prolongs the time it takes for blood to clot PT

Question 25

target INR for warfarin is?

Answer 25

2-3

Question 26

what kind of things can affect warfarin in body?

Answer 26

food rich in vitamin K leafy green vegetables or those affected p450 i.e cranberry juice/alcohol

Question 27

half life of warfarin is?

Answer 27

1-3 days

Question 28

how long is half life of NOACs?

Answer 28

7-15 hours, apixaban-12 hours

Question 29

what can be used to reverse apixaban and rivaroxaban?

Answer 29

andexanet alfa

Question 30

what can be used to reverse dabigatran?

Answer 30

idarucizumab

Question 31

DOACs are better then warfarin because?

Answer 31

No monitoring is required
No major interaction problems
Equal or slightly better than warfarin at preventing strokes in AF
Equal or slightly less risk of bleeding than warfarin

Question 32

what is CHA2DS2VAS score?

Answer 32

Assessing risk of giving someone with AF anticoagulants.
C – Congestive heart failure
H – 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 33

what is orbit used for?

Answer 33

Assessing someones bleeding risk whilst on anticoagulants
BRAAH
Low haemoglobin or haematocrit
Age (75 or above)
Previous bleeding (gastrointestinal or intracranial)
Renal function (GFR less than 60)
Antiplatelet medications

Question 34

another risk of bleeding score is?

Answer 34

HAS BLED
H – Hypertension
A – Abnormal renal and liver function
S – Stroke
B – Bleeding
L – Labile INRs (whilst on warfarin)
E – Elderly
D – Drugs or alcohol

Question 35

What causes AF?

Answer 35

sepsis
mitral valve pathology
ischaemic heart disease
thyrotoxicosis
hypertension

alcohol and caffeine

Question 36

normal ECG and paroxysmal atrial fibrillation further investigations?

Answer 36

24 hour ambulatory ECG (holter monitor)
cardiac event recorder lasting 1-2 weeks

Question 37

in delayed cardioversion what should be done?

Answer 37

electrical cardioversion recommended. transeosophageal echocardiography guided cardioversion. Amiodarone before and after electrical cardioversion to prevent AF from recurring.

Question 38

1st line for anticoagulation?

Answer 38

DOACs

Question 39

role of apixaban and rivaroxaban?

Answer 39

direct factor Xa inhibitors

Question 40

dabigatran is?

Answer 40

direct thrombin inhibitor