Atrial Fibrillation

Question 1

What is paroxysmal AF?

Answer 1

Episodes lasting between 30 seconds and 7 days that are self-terminating and recurrent

Question 2

What is persistent AF?

Answer 2

Episodes lasting longer than 7 days (spontaneous termination of the arrhythmia is unlikely to occur after this time)

Question 3

What is permanent AF?

Answer 3

AF that fails to terminate using cardioversion, or AF that is terminated but relapses within 24 hours, or longstanding AF (usually > 1 year) in which cardioversion has not been indicated/attempted.

Question 4

What are the 3 ECG signs of AF?

Answer 4

1. Absolute irregular RR intervals
2. Absent p waves
3. Rapid and chaotic atrial activity

Question 5

What are some causes of AF?

Answer 5

IHD, valvular disease, HTN, hyperthyroidism, acute infection, dietary factors (caffeine, alcohol)
Lone AF (no cause) occurs in 11% of those with AF

Question 6

What investigation should be ordered if paroxysmal AF is suspected?

Answer 6

Ambulatory ECG

Question 7

What scoring tool can be used to assess stroke risk for patients with AF?

Answer 7

CHA2DS2-VASc score
C - Congestive heart failure = 1
H - HTN > 140/90 = 1
A - Age > 75 = 2
D - Diabetes = 1
S - Stroke previously = 2
V - Vascular disease (PAD/IHD) = 1
A - Age 65-74 = 1 
S - Sex category (female) = 1

Question 8

At what CHA2DS2-VASc score does NICE recommend starting anticoagulation treatment (DOAC or warfarin) for men and women, after taking into account bleeding risk?

Answer 8

Men: Score >= 1
Women: Score >= 2

Question 9

What tool is used to assess bleeding risk in patients to be started on anticoagulation?

Answer 9

HASBLED - max score of 9. Score > 3 = high risk of bleed so caution using anticoagulants.
H - Hypertension SBP >160 = 1
A - Abnormal liver/renal function = 1 point each
S - Stroke in past = 1
B - Bleeding Hx or anaemia = 1
L - Labile INR = 1
E - Elderly (> 65) = 1
D - Drugs (NSAIDs/aspirin etc) or alcohol = 1 point each

Question 10

What is the first line option in long term management of AF?

Answer 10

Rate control using either a beta-blocker (e.g. atenolol) or cardioselective CCB (e.g. diltiazem, verapamil) depending on patient’s co-morbidities.
Conisder digoxin monotherapy for sedentary patients with paroxysmal AF.
If monotherapy does not control Sx, consider dual therapy with 2 of: beta-blocker/diltiazem/digoxin.

Question 11

When should patients be offered rhythm control for AF?

Answer 11

Consider rhythm control if rate has been controlled but symptoms continue, or rate control has been unsuccessful, or new onset AF, AF has a reversible cause (e.g. chest infection).

Question 12

What medication should be offered for rhythm control for AF lasting less than 48 hours?

Answer 12

A beta-blocker

Question 13

What should be offered for rhythm control for AF persisting over 48 hours?

Answer 13

Electrical cardioversion.

Consider amiodarone for 4 weeks prior and 12 months after electrical cardioversion to maintain sinus rhythm.

Question 14

If AF is paroxysmal or triggers are known (e.g caffeine, alcohol), what medication could be considered?

Answer 14

Flecainide - the ‘pill in the pocket’

Question 15

What should be offered to patients with AF if rhythm is inadequately controlled with medication?

Answer 15

Left atrial ablation - more effective in paroxysmal than permanent AF

Question 16

What should be offered to patients with permanent AF if rhythm is inadequately controlled with medication?

Answer 16

Pacemaker insertion

Question 17

What is the acute management strategy for life-threatening haemodynmic instability AF?

Answer 17

Emergency electrical cardioversion

Question 18

What is the acute management strategy for AF patients with haemodynamic instability that is not life-threatening?

Answer 18

If onset of AF is < 48 hours, rate and rhythm control - consider flecainide, amiodarone or electrical cardioversion.
If onset > 48 hours, start rate control.
Consider anticoagulation (with heparin initially) if new onset AF and not on any other anticoagulants.

Question 19

When should AF patients be followed up if started on rate control treatment?

Answer 19

1 week. Check tolerance, S/E, HR, BP. Alter if necessary.

Question 20

Which beta blocker must not be offered for rate control of AF?

Answer 20

Sotalol

Question 21

What constitutes poor anticoagulant control in patients with AF taking AF?

Answer 21

Time in Therapeutic Range (TTR) < 65% over last 6 months
2 INR values > 5 in last 6 months
1 INR value > 8 in last 6 months
2 INR values < 1.5 in last 6 months
If anticoagulation can’t be correctly controlled, consider switching to DOAC