ATRIAL FIBRILLATION Flashcards
Atrial fibrillation
fast and irregular heart rhythm originates in atria, overriding the SAN which is the hearts natural pacemaker
leads to irregular ventricular rhythm
AF and stroke
- increases risk of stroke
- CHA2D2Vasc
- men 1, women 2
- Give DOAC
What complications can AF lead to?
Stroke
Clot - blood doesn’t fully eject
ventricular rate of untreated AF
160-180bpm, typically slower in elderly
Ectopic beats
spontaneous
rarely requires treatment
if treatment needed: beta blockers
What are the two
types of management approaches for AF?
Rate control
- Controlling the ventricular rate
AND
Rhythm control
- Maintaining sinus rhythm
Rate control is first line in AF, except in patients…
- AF with a reversible cause
- Heart failure caused by AF
- New-onset (<48 hours) AF, in which case you give rhythm control (as it is preferred)
- Or when rhythm control is deemed more suitable
What is acute/ new onset AF?
- AF occuring within 48H
Haemodynamic instability
- Symptomatic hypotension
- Acute HF
- Unstable angina
- Loss of consciousness
Treatment of acute AF
Patients with life-threatening haemodynamic instability caused by AF:
- Emergency electrical cardioversion
- Must not wait until anticoagulation is achieved - must be adminstered parenteral anticoagulation e.g. heparin
Treatment of acute AF
Patients without life-threatening haemodynamic instability:
- If onset of AF is < 48 hours → rate OR rhythm control
- If onset of AF is > 48 hours → rate control
If onset of AF is < 48 hours
- Rhythm control preferred
- Determine whether there is any structural or ischaemic heart disease present
YES = IV amiodarone only
NO = IV fleicanide/ IV amiodarone
What is suggestive of structural or ischaemic heart disease?
- Left ventricular hypertrophy
- Bundle branch block
- Cardiomyopathy
- Ischaemia
Can IV Flecainide be given to someone who has structural/ ischaemic heart
disease and has acute
AF occurring within 48 hours?
NO
Only IV Amiodarone
What about if urgent rate control is needed rather than rhythm in those who have acute
AF within 48 hours, what medication would you give?
IV Verapamil or IV beta-blocker can be given
If onset of AF is > 48 hours
Rate OR Rhythm control based on clinical circumstance
- However, Rate control is more preferred
If Rhythm control is chosen for those who have acute AF more than 48 hours, what does it involve?
- Electrical cardioversion (rather than pharmacological in <48 hours acute AF)
Which pharmacological cardioversion
medication may be considered before and after electrical cardioversion?
- Amiodarone may be considered
- 4 weeks before electrical cardioversion
- Continue for up to 12 months after electrical cardioversion to maintain sinus rhythm
How must those who are undergoing electrical
cardioversion as part of rhythm control in acute AF >48 hours/ uncertain receive anticoagulation?
- Anti-coagulate for 3 weeks
- Give rate control therapy in the mean time
- Undergo electrical cardioversion
What happens if
urgent anticoagulation therapy is needed prior to electrical cardioversion?
Give parenteral anticoagulation e.g. Heparin
Oral anticoagulation should then be given after
cardioversion and continued for at least 4 weeks
Maintenance treatment of AF
Rate control with monotherapy
1. beta blocker (not sotalol)
or
2. rate limiting CCB = diltiazem or verapamil
3. digoxin
Rate control with dual therapy: 2 of the above drugs
Rhythm control
When would you consider rate control treatment of AF with digoxin
- Digoxin is ONLY effective at rest
- Therefore it is given to those who are sedentary
- It may also be used in those with congestive heart failure
If monotherapy fails in rate control for AF, what do you do?
Combination, so 2 of either:
- Beta-blocker
- Digoxin
- Diltiazem
If combination therapy fails, what do you do?
Consider Rhythm control
* pharmacological or electrical is based on clinical judgement
* Electrical would be preferred in Non-acute AF, since it would have lasted more than 48 hours
What is involved in pharmacological rhythm control for non-acute AF?
- First Line Standard Beta-blocker (not sotalol)
- If contraindicated or unsuccesstul, consider Oral anti-arrhythmic drugs such as:
- Sotalol
- Flecainide
- Propafenone
- Dronedarone
- Amiodarone
Maintenance: if AP present > 48 hours
electrocardioversion preferred
pt must be fully anticoagulated for at least 3 weeks
PO - continued for at least 4 weeks after cardio version
Drug treatment post cardio version
- BB
- Other antiarrythmic drug
Fleicanide
Propafenone
Amiodarone
Dronedarone
Sotalol
F PADS
Paroxysmal AF treatment
- BB (not sotalol)
- if symptoms persist or a standard BB not appropriate = F PADS
What is the pill in the pocket?
- For P AF - some pt may have infrequent episodes
- pt takes oral fleicanide/ propafenon prn with symptoms
Which class of anti arrhythmic drugs should not be given to pt with ischaemic or structural heart disease
class 1c: e.g. flecainide, propafenone
Overall which drugs are given for rate control?
- Main BB (not sotalol) and RL CCB (e.g. diltiazem, verapamil)
- Digoxin - only in sedentary pt and in HF
Overall which drugs are given for rhythm control?
F PADS
