atrial fibrillation Flashcards
Rate control is the preferred first line treatment strategy for AF except in pt with….
- new onset AF
- atrial flutter suitable for ablation strategy
- AF with reversible cause
- HF primarily caused by AF
- if rhythm control more suitable based on clinical judgement
treatment of life threatening haemodynamic instability caused by new onset AF
emergency electrical cardioversion w/o delaying to achieve anticoagulation
acute AF w/o life threatening haemodynamic instability - treatment options
if onset <48h, give rate or rhythm control
if onset >48h or uncertain, rate control is preferred
If AF <48h onset, rate or rhythm. But which one is generally preferred?
Eate control is still acceptable for <48-hour AF (especially if symptoms are mild or moderate), rhythm control is often considered first if it’s practical, safe, and beneficial for symptom relief or quality of life. This is because the patient has low clot risk, and it provides early rhythm restoration and prevents progression to persistent AF
A 45-year-old active individual with no significant past medical history presents with new-onset AF that started 6 hours ago. They complain of severe palpitations, chest discomfort, and shortness of breath, and their heart rate is persistently around 150 beats per minute. The patient finds these symptoms distressing and is otherwise healthy. What treatment would you offer?
Options in new onset AF <48 h = rate or rhythm
However, this patient is presenting with more severe symptoms so you would want to go for rhythm control to achieve more rapid control of sinus rhythm
They also have low risk of blood clot since it’s <48h, hence why rhythm is an option
A 70-year-old with a history of hypertension and well-controlled diabetes presents with new-onset AF for the past 24 hours. They experience mild palpitations and some fatigue but are generally comfortable, with no signs of hemodynamic instability. Their heart rate is around 120 beats per minute, and their symptoms are not distressing. What treatment would you offer?
Options in AF <48h = rate or rhythm depending on presentation
for this patient, give RATE CONTROL
- The symptoms are manageable, and immediate rhythm restoration isn’t urgent.
- The patient has comorbidities that might make AF recurrence more likely, so focusing on rate control could help manage symptoms without the need for rhythm control.
- Rate control also allows time to assess the underlying cause and determine whether long-term rate control or rhythm control might be needed later.
Why is rate control preferred if onset AF >48h or unknown?
With AF that’s lasted more than 48 hours (or an unknown duration), there’s a higher risk of blood clot formation in the heart compared to new onset because the blood has had longer time to pool in the atria compared with new onset <48h.
Attempting to restore normal rhythm (rhythm control) could dislodge these clots, leading to a stroke or other complications.
To proceed safely with rhythm control in these cases, patients usually need to be anticoagulated for 3 weeks before attempting cardioversion.
Therefore, rate control is preferred and rhythm control is typically deferred until anticoagulation is managed, unless in an emergency e.g. haemodynamic instability.
options if urgent rate control needed
IV BB or verapamil
avoid verapamil if LVEF less than 40%
rate control if suspected concomitant acute decompensated HF
avoid CCBs - make HF worse (reduce cardiac contracility)
seek specialist advice re use of BB
discuss use of cardioversion in AF
- electrical cardioversion and pharmacological (with fleicanide or amiodarone)
- electrical preferred in AF >48h but needs to be delayed until pt has been anticoagulated for 3 weeks (use rate control in interim)
emergency electrical cardioversion
without delaying to achieve anticoagulation
- rule out left atrial thrombus
- start parenteral heparin AC immediately before cardioversion
- give oral AC after cardioversion and continue for at least 4 weeks
use of amiodarone with electrical cardioversion
amiodarone started 4 weeks before electrical cardioversion and continued for up to 12 months after should be considered to maintain sinus rhythm
what should you offer if drug treatment if needed to maintain sinus rhythm post cardioversion
i.e. rhythm control
- standard BB, not sotalol
- SPAF
which anti arrhythmics must you avoid in ischaemic (e.g. PAD, CHD, angina, atherosclerosis) or structural heart disease
fleicanide and propfaneone (group 1c)
which anti arrhtyhmic should you consider if pt has HF or LV impairment
amiodarone
