Atrial Fibrillation

Question 1

What is the CHA2DS2VASc score?

Intepretation?

Answer 1

1 - Congestive heart failure or decreased LV ejection fracture
1- Hypertension (>140/90, on more than 2 occasions, or on antihypertensive therapy)
2- Age 75 years or older
1-Diabetes
2-History of stroke, TIA or thromboemolism
1-Vascular disease (previous MI, PVD or aortic plaque disease)
1-Age 65-74 years
1-Female Sex

• Score -1 consider Anticoagulation
• Score greater than or equal to 2 Anticoagulation should be considered
• Males, score >3 = anticoagulation
• Females, score >3 = anticoagulation

(Ref:ESC Guidelines 2014)

Question 2

When would you consider NOACs vs Warfarin?

Answer 2

"Non valvular" (considered a historic term now) disease = NOAC 
Vavular disease (mitral valve stenosis, mechanical heart valves ) = Warfarin 

(Ref: ESC Guidelines page 19)

Question 3

MR and aortic valve disease need to be considered when choosing anticoagulation?

Answer 3

Nil evidence for its consideration
(although recent talk = consider warfarin for short term in TR and MR)
(Ref: ESC Guidelines page 19)

Question 4

Aim for heart rate in management of AF (long term ?)

Answer 4

Nil optimal range
Aim <110
(Ref ESC Guidelines 10.3)

Question 5

When may Warfarin be considered for AF?

Answer 5

Mechanical Heart Valves 
Poor compliance (so can check INR) 
Long term well controlled patient on Warfarin
Poor renal function 
History of GI bleed 
Drug interaction with a NOAC 

(Reference: Talk on AF August 2017)

Question 6

How common is AF in the
< 60 year age group?
>80 year age group?

Answer 6

1%
5-15%

(Ref: Red book)

Question 7

What is the approach to management of a patient with AF?

Answer 7

1. decrease stroke risk and assess bleeding risk
2. decrease heart rate
3. if symptomatic - consider rhythm control
4. manage cormorbidities
   BSL control in diabetes
   antihypertensives & statins
   heart failure therapy
   valve repair or replacement
5. exercise, nutrition
6. preventative measures e.g. vaccinations
7. patient education

Question 8

Which rate control agent would you use for
1/ LVEF >40%
2/ LVEG <40%

Answer 8

1/ beta blocker, diltiazem/verapamil, digoxin

2/ beta blocker and or digoxin

Question 9

Causes of AF

Answer 9

P
Pulmonary embolus
COPD
Pericardial disease

I
Iatrogenic (e.g. drugs, sympathomimetics) 
Infections 
Infarction 
Ischemic Heart Disease 

R - Rheumatic Heart Disease/ Valvular Heart Disease

A - Alcohol

T - Thyrotoxicosis

E - Electrolyte disturbance (hypokalaemia, hypomagnesaemia)

S

H - Hypertension

I - Ischaemic heart disease

P

Cardiomyopathies: dilated, hypertrophic.
Phaeochromocytoma)

Ref Lifeinthefastlane

Question 10

1/ When is AF classified as having a rapid ventricular response?

2/ ‘Slow’ AF is a term often used to describe AF with a ventricular rate < 60 bpm. What are some causes?

Answer 10

1/AF is often described as having ‘rapid ventricular response’ once the ventricular rate is > 100 bpm.

2/Causes of ‘slow’ AF include hypothermia, digoxin toxicity, medications, and sinus node dysfunction

Ref Lifeinthefastlane