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
for a patient with AF that you may suspect has CAD, what additional test would you do?
stress test
26
hemodynamic instability present with what symptoms?
``` 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
27
goals of AF therapy
control symptoms if present | prevent thromboembolism
28
example circumstances where urgent/emergent cardioversion may be needed
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
29
reasons to admit for AF
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
in rate control, drugs are used to slow conduction through ____.
AV node
31
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.
rate control
32
if a patient is hemodynamically unstable, would you use rate or rhythm control?
rhythm | need to cardiovert
33
most patients with AF will require slowing of _______ to improve symptoms
ventricular rate
34
rate control medications
1. beta blockers 2. calcium channel blockers - verapamil or diltiazem 3. digoxin: only used in HF patients
35
rhythm control options
1. anti arrhythmic drug therapy 2. percutaneous catheter ablation 3. surgical procedures
36
____ control us more often used in patients with asymptomatic or mildly symptomatic AF and are older than 65 yrs old
rate control
37
____ control us typically used in symptomatic patients younger than 65
rhythm
38
when selecting a beta blocker for AF, would you use propranolol?
no, it is not cardioselective
39
potential indications of cardiversion
``` hemodynamic instability first episode long term rhythm control symptomatic or persistant AF infrequent symptomatic episodes potentially reversible cause ```
40
when not to cardiovert
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
the most serious, common complication of AF is ___
arterial thromboembolism
42
the most clinically evident TE event is ____.
ischemic stroke
43
risk factors for TE event
rheumatic mitral stenosis, prosthetic heart valves Age older 65 prior stroke/TA DM HTN
44
method to evaluate need for antithrombotic therapy?
CHA2DS2-VASc score
45
CHA2DS2-VASc score | what is each category?
``` 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
anyone with a CHA2DS2-VASc score of ___ needs to be treated on antithrombotic therapy
2
47
patients who require antithrombotic therapy
1. anyone considered for cardioversion | 2. those who meet criteria for long term anticoagulation
48
what does the CHA2DS2-VASc score of 2 mean?
strongly reccomend that non valvular AF patients receive oral anticoagulation benefit exceeds risk for almost all patients
49
What does the CHA2DS2-VASc score of 1 mean
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
what does a CHA2DS2-VASc score of 0 mean
no anticoagulation is recommended for majority of patients
51
For an AF patient that has had it more than 48 hours, what should anticoagulation protocol be?
give oral anticoagulation at least 3 weeks prior to cardioversion and use for 4 weeks of oral anticoagulation after
52
For an AF patient that has had it less than 48 hours, what should anticoagulation protocol be?
can depend on whether anticoagulation is used, use clinical judgement
53
reasons to anticoagulate before and after cardioversion
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
types of anticoagulants used for AF
1. direct thrombin inhibitor 2. factor Xa inhibitor 3. vitamin K antagonist
55
which anticoagulant is indicated for A-fib with valvular disease
vitamin K antagonist- warfarin
56
_____ have shown similar or lower risk of ischemic stroke and major bleeding events vs warfarin in nonvalvular AF
DOACs
57
advantages of DOACs
convenience- no routine INR testing high relative reduction in ICH lack of susceptibility to dietary interactions reduced susceptibility to DDI
58
disadvantages of DOACs
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
situations in which you may prefer warfarin
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
what DOAC should you use for ESRD
apixaban
61
could you use ASA alone as an anticoagulant
no
62
what can you use in patients that can't be treated with anticoagulant
aspirin and clopidogrel
63
most patients will not need bridging with IV ____ heparin
unfractionated
64
if bridging is needed, what heparin should you use?
LMWH
65
when should you consider bridging anticoagulant in an AF patient?
if deemed high risk for TE event but low risk for hemorrhage
66
do you bridge a patient with nonvalvular AF with acute stroke?
no, ischemic stroke could turn into hemorrhagic stroke
67
for first episode of AF, is electrical or pharm cardioversion preferred?
electrical
68
for paroxysmal AF, is drug or electrical therapy preferred?
drug
69
possible indications for hospitalizations with patients with AF
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
follow up appointments in patients with AF should usually be seen again in ___.
1 week