Atrial Fibrillation

Question 1

What are the different types of AF

Answer 1

Paroxysmal
Persistent
Permanent

Question 2

What is paroxysmal AF

Answer 2

Self-limiting
Less than 7 days
Recurs

Question 3

What is persistent AF

Answer 3

Lasts over 7 days
Is not self-limiting
Cardioversion often attempted
May recur

Question 4

What is permanent AF

Answer 4

Failed cardioversion

No further attempt to return to sinus rhythm

Question 5

How do you manage paroxysmal AF

Answer 5

If rare and brief, it may be ignored

If frequent:-
Drugs to prevent episodes
Self-administered drugs to stop attacks after onset ("pill in the pocket")
Possible ablation if drugs ineffective
Anticoagulate if episodes continue

Question 6

What drugs are used to prevent episodes of paroxysmal AF

Answer 6

Amiodarone
Sotalol
Propafenone
Flecainide

Question 7

What are some side effects of amiodarone

Answer 7

Slate grey pigmentation of skin after exposure to sunlight
Abnormal LFTs
Lung fibrosis
Abnormally low BP

Many others

Question 8

What drugs are used as “pill in the pocket”

Answer 8

Flecainide (most commonly)

Propafenone

Question 9

How do you manage persistent AF

Answer 9

Attempt cardioversion
May have better outcomes if giving anti-arrhythmic drugs before and after cardioversion for 3-4 weeks
If arrhythmia is present for over 48 hrs, anticoagulation is necessary

Question 10

For how long should you anticoagulate a patient with persistent AF

Answer 10

Around 3 weeks pre and post cardioversion

Long term if cardioversion is unsuccessful

Question 11

What is cardioversion

Answer 11

Rhythm control

Can be DC (direct current) or pharmacological

Question 12

What medications are used for pharmacological cardioversion

Answer 12

Flecainide

Amiodarone

Question 13

In what cases is cardioversion unlikely to succeed

Answer 13

AF present for over a year
Valve disease
Poor LV function
Uncontrolled hypertension

Question 14

What is rate control

Answer 14

Control of the ventricular rate to reduce symptoms
Can be used as an alternative to rhythm control if cardioversion contraindicated or patient
doesn’t want it
Used in permanent AF (failed cardioversion)
Delivered in combination with anticoagulation

Question 15

What medication is used for rate control

Answer 15

Beta-blocker
Rate-limiting calcium channel blocker (eg. diltiazem, verapamil)

NEVER combine the two - can cause bradycardia

Question 16

What is the problem with digoxin as a rate-controlling drug

Answer 16

It is good at controlling ventricular rate at rest, but not during exercise

Question 17

What medication is used as anticoagulation in AF

Answer 17

Warfarin (LMWH as bridging agent)
NOAC (new oral anti-coagulant)

*Aspirin no longer used as not effective

Question 18

What are the NOACs

Answer 18

Thrombin antagonist - dabigatran
Factor Xa antagonists - rivaroxaban, apixaban

*Doses more predictable than with warfarin, and fewer interactions

Question 19

What is a downside of NOACs

Answer 19

They don’t have antidotes like warfarin (vit K)

Expensive

Question 20

What is AF

Answer 20

Uncoordinated and disordered contraction of the atria at a fast rate, which leads to initiation of ventricular contraction at varying intervals

Question 21

What is the major risk factor for AF

Answer 21

Age

Question 22

What are some causes of AF

Answer 22

LONEly CHAV

Lone AF (no structural heart disase or cause found)
Coronary artery disease
Hypertension
Alcohol
Valvular heart disease (esp. mitral stenosis)

*Other acute medical conditions:-
Infections/sepsis (esp. pneumonia)
PE
Thyrotoxicosis
Non-cardiac surgery

Question 23

What are the symptoms of AF

Answer 23

Often asymptomatic

Palpitations - if ventricular response is slow or fast
SOB, peripheral oedema and syncope - if a fast rate reduces ventricular filling
Chest pain - if coronary artery disease

Question 24

What is seen on an ECG of a patient with AF

Answer 24

No P waves

Varying intervals between QRS complexes

Question 25

How can paroxysmal AF be detected

Answer 25

Using a Holter monitor

Question 26

What surgical options are available for AF

Answer 26

Pulmonary vein ablation

Question 27

What is pulmonary vein ablation

Answer 27

Procedure carried out using a catheter inserted from the groin into the left atrium and into the ostia of the pulmonary veins
Stop ectopic beats travelling from the pulmonary veins from initiating AF

Question 28

What is the CHA2DS2-VASc score

Answer 28

Calculates stroke risk for patients with AF

Congestive heart failure
Hypertension (BP consistently over 140/90)
Age over 75 (2 points)
Diabetes mellitus
Stroke or TIA or thromboembolism previously (2 points)
Vascular disease
Age 65-74
Sex category (ie. male or female)

Max score 9 - stroke risk 15%

Question 29

What is the HAS-BLED score

Answer 29

Estimates risk of major bleeding for patients on anticoagulation for AF

Hypertension
Abnormal renal and liver function (1 point for each)
Stroke
Bleeding
Labile INRs (time in therapeutic range less than 60%)
Elderly - age over 65
Drugs or alcohol (1 point for alcohol, 1 point for medication predisposing to bleeding)

Question 30

What are the common causes of AF?

Answer 30

Cardiovascular disease: HTN, HF and MI

Valvular: Mitral valve disease

Toxins: Alcohol-related heart disease

Infection (e.g. resp, urinary)

Iatrogenic: Post-surgical (especially cardiothoracic)

Endocrine: Thyrotoxicosis

Question 31

What INR do you aim for in AF?

Answer 31

2-3