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block 3 fcm > Atrial Fibrillation > Flashcards

Atrial Fibrillation Flashcards

1
Q

A fib is a common cardiac arrhythmia with EKG characteristics of?

A
  1. no repetitive pattern of R-R intervals
    irregularly irregular
  2. no distinct p waves
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2
Q

problems with having a-fib?

A

decreased cardiac output
increased risk for thrombus formation
increased risk for arrhythmias

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3
Q

pathogenesis of A-fib.

A

usually some underlying heart disease causes multiple wavelet formation in the atria

as AF becomes established, the refractory period of atrial muscle shortens so these electrophysiologic changes predispose to further AF

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4
Q

long standing hypertension causes ___

A

hypertrophy

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5
Q

prevalence and incidence of A- fib increase with ___ and with presence of ____disease

A

age

presence of CV disease

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6
Q

do men or women have higher risk of a-fib?

A

men

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7
Q

potential risk factors for a-fib

A 
hyperthyroidism
surgery: cardiac as well as non-cardiac
family hx or genetics
low birth wt
inflammation and infection
pericardial fat
PACs
other SVTs
low Mg
ETOH consumption
medications- anything that can affect HR can cause arrhythmia
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8
Q

chronic disease associations with a-fib

A

two most common:

  1. hypertension
  2. coronary heart disease

common in undeveloped countries: rheumatic heart disease

other associations:
valvular heart disease
HF
hypertrophic cardiomyopathy
congenital heart disease
COPD
OSA
UTE diseases
DM
metabolic syndrome
CKD
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9
Q

Acute AF etiology

PIRATES

A 
P: Pulmonary disease
I: ischemia
R: rheumatic heart disease
A: anemia/ atrial myixema
T: thyrotoxicosis
E: ethanol
S: sepsis
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10
Q

Chronic AF etiology

A

HTN

CHF

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11
Q

what is A-fib with RVR

A

Atrial fibrillation with rapid ventricular rate, over 100

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12
Q

what is Paroxysmal AF

A

a-fib terminates spontaneously or with intervention within 7 days of onset

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13
Q

what is persistent AF

A

A-fib that fails to self terminate within 7 days

often requires drug or electrical cardioversion

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14
Q

what is long standing persistent AF?

A

A-fib that lasts more than 12 months

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15
Q

What is permanent AF?

A

persistent AF where joint decision is made to no longer pursue a rhythm control strategy

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16
Q

in ______ AF, myocytes are still relatively healthy and can revert back to sinus rhythm within 7 days

A

paroxysmal

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17
Q

Prevention of AF

A

Physical activity and weight loss

Mediterranean diet

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18
Q

Symptoms of patient with AF

A 
not all are symptomatic
could be presenting with embolus-stroke
typical features:
-fatigue
-SOB
- Palpitations/ tachycardia
- weakness
-lightheardedness
- generalized malaise

more severe symptoms:

  • dyspnea at rest
  • angina
  • presyncope/syncope
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19
Q

precipating causes that could cause AF

A

alcohol
emotion
exercise

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20
Q

potentially reversible causes of AF

A

hyperthyroidism

alcohol excess

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21
Q

diagnostic tests for AF

A 
ekg
blood tests
echo
holder monitor 
stress test
chest x ray
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22
Q

what lab tests would you do in pt with AF?

A 
TSH, T4
CBC
BMP/CMP
Urine for protein
glucose for A1C
troponin
magnesium
phosphorus
BNP
PT/INR, aPTT
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23
Q

two types of echo that can be done on pt with AF

A
  1. transthoracic echo (TTE)
    - evaluate size of atria
    - size/function of ventricles
    - detect valvular disease, LVH, pericardial disease
  2. transesophageal echo (TEE)
    - select patients to assess for thrombi in Left atrium of left atrial appendage
    - clots can move in cardioversion- so need to check risk for thrombus already formed
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24
Q

what test must you get if you suspect AF

A

EKG

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25
Q

for a patient with AF that you may suspect has CAD, what additional test would you do?

A

stress test

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26
Q

hemodynamic instability present with what symptoms?

A 
BP is low or high
patient in distress
tachypnea
oxygen is low
cyanotic
syncopal

all this means they aren’t getting enough perfusion to the tissues

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27
Q

goals of AF therapy

A

control symptoms if present

prevent thromboembolism

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28
Q

example circumstances where urgent/emergent cardioversion may be needed

A
  1. acute ischemia
  2. evidence of organ hypo perfusion (cool clammy skin, confusion, acute kidney injury)
  3. severe manifestations of HF (pulmonary edema)
  4. hemodynamic instability
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29
Q

reasons to admit for AF

A

management of HF or hypotension after control of rate or rhythm

initiation of antiarrythmic drug

treat associated medical problems- HTN, thyroid storm, infection, COPD, PE, cardiac ischemia, etc.

30
Q

in rate control, drugs are used to slow conduction through ____.

A

AV node

31
Q

for most patients who are with new onset AF and who are in the AF at the time of presentation, ______ control will precede any attempt to restore sinus rhythm.

A

rate control

32
Q

if a patient is hemodynamically unstable, would you use rate or rhythm control?

A

rhythm

need to cardiovert

33
Q

most patients with AF will require slowing of _______ to improve symptoms

A

ventricular rate

34
Q

rate control medications

A
  1. beta blockers
  2. calcium channel blockers - verapamil or diltiazem
  3. digoxin: only used in HF patients
35
Q

rhythm control options

A
  1. anti arrhythmic drug therapy
  2. percutaneous catheter ablation
  3. surgical procedures
36
Q

____ control us more often used in patients with asymptomatic or mildly symptomatic AF and are older than 65 yrs old

A

rate control

37
Q

____ control us typically used in symptomatic patients younger than 65

A

rhythm

38
Q

when selecting a beta blocker for AF, would you use propranolol?

A

no, it is not cardioselective

39
Q

potential indications of cardiversion

A 
hemodynamic instability
first episode
long term rhythm control
symptomatic or persistant AF
infrequent symptomatic episodes
potentially reversible cause
40
Q

when not to cardiovert

A

minimal to no symptoms
low likelihood of success:
- AF continuously for more than 1 year
- left atrium markedly enlarged
- AF recurrence while taking antiarrhytmic drug
- when underlying precipitant has not been corrected- pericarditis, thyrotoxicosis, etc.

41
Q

the most serious, common complication of AF is ___

A

arterial thromboembolism

42
Q

the most clinically evident TE event is ____.

A

ischemic stroke

43
Q

risk factors for TE event

A

rheumatic mitral stenosis, prosthetic heart valves

Age older 65
prior stroke/TA
DM
HTN

44
Q

method to evaluate need for antithrombotic therapy?

A

CHA2DS2-VASc score

45
Q

CHA2DS2-VASc score

what is each category?

A 
C- congestive HF or LV dysfunction
H- HTN 
A2- age over 75
D- DM
S2- prior Stroke or TIA or TE
V- vascular disease
A- age- 64-75 yrs
Sc- sex category (female)
46
Q

anyone with a CHA2DS2-VASc score of ___ needs to be treated on antithrombotic therapy

A

2

47
Q

patients who require antithrombotic therapy

A
  1. anyone considered for cardioversion

2. those who meet criteria for long term anticoagulation

48
Q

what does the CHA2DS2-VASc score of 2 mean?

A

strongly reccomend that non valvular AF patients receive oral anticoagulation
benefit exceeds risk for almost all patients

49
Q

What does the CHA2DS2-VASc score of 1 mean

A

more variability than with score of 2 or more
age is more significant risk factor, can use to determine therapy
clinical judgment will play important role in helping patient choose between anticoagulation and no anticoagulation

50
Q

what does a CHA2DS2-VASc score of 0 mean

A

no anticoagulation is recommended for majority of patients

51
Q

For an AF patient that has had it more than 48 hours, what should anticoagulation protocol be?

A

give oral anticoagulation at least 3 weeks prior to cardioversion and use for 4 weeks of oral anticoagulation after

52
Q

For an AF patient that has had it less than 48 hours, what should anticoagulation protocol be?

A

can depend on whether anticoagulation is used, use clinical judgement

53
Q

reasons to anticoagulate before and after cardioversion

A

most embolic events occur within ten days of cardioversion

patients undergoing cardioversion of AF more than 48 hours duration are a high risk group for embolic event

54
Q

types of anticoagulants used for AF

A
  1. direct thrombin inhibitor
  2. factor Xa inhibitor
  3. vitamin K antagonist
55
Q

which anticoagulant is indicated for A-fib with valvular disease

A

vitamin K antagonist- warfarin

56
Q

_____ have shown similar or lower risk of ischemic stroke and major bleeding events vs warfarin in nonvalvular AF

A

DOACs

57
Q

advantages of DOACs

A

convenience- no routine INR testing
high relative reduction in ICH
lack of susceptibility to dietary interactions
reduced susceptibility to DDI

58
Q

disadvantages of DOACs

A

lack of efficacy and safety in CKD
lack of easy monitoring of blood levels and compliance
higher cost
unknown potential ADRs with continued long term use

59
Q

situations in which you may prefer warfarin

A

already on warfarin
prosthetic heart valves, rheumatic mitral valve disease, mitral stenosis, and other valve diseases
not likely to comply with dosing of DOACs
cost
CKD with GFR less than 30
if DOAC is CI, especially due to DDIs

60
Q

what DOAC should you use for ESRD

A

apixaban

61
Q

could you use ASA alone as an anticoagulant

A

no

62
Q

what can you use in patients that can’t be treated with anticoagulant

A

aspirin and clopidogrel

63
Q

most patients will not need bridging with IV ____ heparin

A

unfractionated

64
Q

if bridging is needed, what heparin should you use?

A

LMWH

65
Q

when should you consider bridging anticoagulant in an AF patient?

A

if deemed high risk for TE event but low risk for hemorrhage

66
Q

do you bridge a patient with nonvalvular AF with acute stroke?

A

no, ischemic stroke could turn into hemorrhagic stroke

67
Q

for first episode of AF, is electrical or pharm cardioversion preferred?

A

electrical

68
Q

for paroxysmal AF, is drug or electrical therapy preferred?

A

drug

69
Q

possible indications for hospitalizations with patients with AF

A

ablation is considered- especially in symptomatic and associated with hemodynamic collapse and RVR

bradycardia after cardioversion

treatment of associated medical problems

elderly patients

further management of HF or hypotension after control of rate to rhythm

imitation of antiarrythmic drug therapy

70
Q

follow up appointments in patients with AF should usually be seen again in ___.

A

1 week

block 3 fcm (7 decks)

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