Atrial Fibrillation

Question 0

What is acute AF?

Answer 0

AF lasting less than 30 seconds diagnosed by ECG

Question 1

How may atrial fibrillation present?

Answer 1

Incidental finding of irregular pulse
SOB
Palpitations
Fatigue
Syncope/dizziness
Chest discomfort
Stroke/TIA

Question 2

What is paroxysmal AF?

Answer 2

Recurrent (>2) episodes that last less than 7 days

Or

Recurrent (>2) episodes that last <48 hours and are stopped with cardioversion

Question 3

What is recurrent AF?

Answer 3

Recurrent episodes:

Continuous for >7 days

Or

Continuous for >48 hours and stopped with cardioversion

Question 4

What is persistent AF?

Answer 4

Continuous AF of greater than 12 months duration

Question 5

What is permanent AF?

Answer 5

Continuous AF, and a joint decision by patient and clinician to cease attempts to revert to systolic rhythm

Question 6

Which patients with an irregular pulse on examination should have an ECG?

Answer 6

All patients with irregular pulse! Trick question

Use ambulatory ECG if symptomatic episodes are 24 hours apart

Question 7

Which patients with suspected AF should have an echo?

Answer 7

Perform echocardiography if:

Baseline echo necessary for long term management

Rhythm control strategy including cardioversion is considered

High risk of structural/functional disease (HF/murmur)

Clinical risk stratification for anti thrombotic therapy is needed

Question 8

When should transoesophageal echo be performed?

Answer 8

If Transthoracic echo reveals abnormality

If transoesophageal guided cardioversion is being considered

Question 9

When is rate control considered for he management of AF?

Answer 9

Offered EXCEPT when:

AF has a reversible cause

Heart failure due to AF

New onset AF

Rhythm control more suitable based on clinical judgement

Question 10

What is rate control of AF?

Answer 10

First line:
Standard beta blocker- eg other than sotalol
Or rate limiting calcium channel blocker- diltiazem
Consider digoxin monotherapy if non paroxysmal

Second line:
If mono therapy does not control symptoms, and poor ventricular rate control - use combination therapy of two of beta blocker, diltiazem digoxin

Question 11

When should rhythm control be used to manage AF?

Answer 11

Consider rhythm control if:

Rate control is not successful

Symptoms persist after heart rate controlled

Question 12

What is involved in rhythm management of AF?

Answer 12

Options are:

Cardioversion

Ablation

Drug treatment

Question 13

What is involved in cardioversion for rhythm control?

Answer 13

For AF persisting longer than 48 hours - use electrical cardioversion not pharmacological

Consider amiodarone pretreatment 4 weeks before for up to 12 months after cardioversion

50% recurrence at 12 months

Question 14

When should ablation for atrial fibrillation be used?

Answer 14

Paroxysmal - if drug treatment has failed
Persistent - use pacing and ablation

70% success rate - may require multiple procedures

2-3% major complication

Question 15

Which drugs can be used for rhythm control?

Answer 15

Beta blockers other than sotalol

Dronedarone - maintains sinus rhythm after successful cardioversion

Amiodarone - if LVF or HF

Flecainide - pill in pocket - for infrequent paroxysmal AF with precipitants

Question 16

Which anticoagulants can be used for thromboprophylaxis in HF?

Answer 16

Apixaban
Dabigatran
Rivaroaxaban
Warfarin

Use these (except warfarin) for non- valvular AF with other risk factors for stroke

Question 17

What score should be used to assess need for oral anticoagulation in patients with AF?

Answer 17

CHADS2VASC

Question 18

What are the components of CHADS2VASC?

Answer 18

CHF or LVEF 
Age >75
Diabetes
Stroke/TIA
Vascular disease
Age 65-74
Sex category (female)

Question 19

What components of CHADS2VASC score two points?

Answer 19

Age >75
Previous stroke /TIA

All the rest score one point

Question 20

At what CHADS2VASC score should oral anticoagulation be offered?

Answer 20

> /= 2 - offer oral warfarin, Apixaban etc

> /= 1 - consider oral anticoagulation

0 - do not offer anticoagulation and do not use aspirin as an anticoagulant

Question 21

What score can be used to asses risk of haemorrhage for patients with AF on anticoagulants?

Answer 21

HASBLED

Question 22

What are the components of HASBLED?

Answer 22

Hypertension
Abnormal liver or renal function (1pt each)
Stroke
Bleeding
Labile INRs
Elderly (age >65)
Drugs or alcohol (1pt each)

Question 23

What HASBLED score indicates increased risk of bleeds?

Answer 23

> /= 3 indicates increased one year bleed risk in anticoagulants, sufficient to justify caution or review

Question 24

When should a patient with AF be admitted to hospital?

Answer 24

Very rapid pulse (>150bpm)
Very low BP (sys <90)
LOC, dizziness, chest pain, SOB
Complication - stroke, TIA, HF

Question 25

When should a patient with AF be routinely referred to a cardiologist?

Answer 25

Age <50
Paroxysmal AF
Uncertainty regarding rate or rhythm control
Valvular disease, WPW, prolonged QT

Question 26

When do cardioverted patients need to be monitored?

Answer 26

1 month and 6 moths after heart rhythm is back to normal

Question 27

When do patients on long term anticoagulation need to be monitored?

Answer 27

INR checked daily until in therapeutic range
INR checked biweekly for 1-2 weeks
INR checked weekly until stable
INR checked every 6-12 weeks from stable

Question 28

What bloods should be done when investigating AF?

Answer 28

FBC 
UandEs
LFTs
TFTs
Clotting 

Consider CXR

Question 29

What lifestyle changes may help AF?

Answer 29

Stop smoking - risk factor for vascular disease as well as precipitants for AF

Alcohol in moderation - may precipitate AF

Caffeine may precipitate AF