Atrial Fibrillation

Question 1

Classification of the progression of AF

Answer 1

Initial episode - <30 seconds
Paroxysmal - Recurrent, >2 episodes in 7 days
Persistent - Continuous, >7 days, or >48hrs then CV
Long standing - AF for >12 months
Permanent - decision to cease attempts to restore SR

Question 2

Signs and symptoms of AF

Answer 2

Palpitations
Hypotension
Tachycardia/irregular pulse
dizziness, syncope, stroke, chest pain/discomfort

Question 3

Investigations for AF

Answer 3

ECG - interim and 24hr if asymptomatic, or event recorder ECG if episodes >24hrs apart

Serum electrolytes - K+, cardiac biomarkers (CK-MB, trop)
TFTs, chest xray
TOE - trans-oesophageal echocardiogram - to visualise clots in atria

Question 4

What scenario warrants immediate referral/admission with AF

Answer 4

Signs of haemodynamic instability

Pulse >150bpm, with SBP <90mmHg
Loss of consciousness, ongoing chest pain/SoB
Complications - Stroke/TIA/acute heart failure

Question 5

3 main principles of AF management

Answer 5

1) Ventricular rate control
2) restoration of sinus rhythm
3) prevention of thrombo-embolic events

Question 6

Agents used for ventricular rate control?

Answer 6

Beta blockers - bisoprolol, atenolol

Non-dihydropyridine CCBs - Diltiazem, verapamil

Digoxin - IF patient in HF, or non-paroxysmal sedentary patients

Question 7

Methods of restoring sinus rhythm

Answer 7

1) Direct Current Cardioversion (under GA)

2) Pharmacological - dronedarone, sotalol, propafenone, flecainide

Question 8

Methods of prevention of thromboembolic events in AF?

Answer 8

Initial - acute - LMWH (S/C) / Heparin IV

Warfarin

DOAC - e.g. dabigatran, rivaroxaban, apixaban, edoxaban

Question 9

Haemodynamically unstable AF - management

Answer 9

1) immediately DC cardiovert - dont wait to anticoagulate

2) anticoagulate with LMWH/Heparin

Question 10

Haemodynamically stable AF, but symptomatic - management

Answer 10

1) rate control therapy until cardioversion successful
- -> beta blocker/CCB, or Digoxin if in HF
2) Rhythm control - DC or pharm (dronedarone/flecainide/amiodarone)
3) Anticoagulate - before, during and after

Question 11

Haemodynamically stable AF, asymptomatic - management?

Answer 11

1) CHA2DS2VASc - guided decision on anticoagulation

Question 12

What anticoagulant medication combination is contraindicated

Answer 12

Heparin + DOAC

Start on Heparin + warfarin, can then make the switch to DOAC after heparin has been stopped

Question 13

What does CHA2DS2VASC score stand for

Answer 13

C = congestive heart failure
H = hypertension
A = Age >75
D = diabetes mellitus
S = stroke
V = vascular disease
A = Age (65-74)
Sc = sex category (female)

Score >1 = consider anticoagulation
Score >2 = offer anticoagulation

Question 14

What does HAS-BLED score stand for?

Answer 14

H = Hypertension (uncontrolled)
A = Abnormal liver/renal function (1 pt each)
S = stroke (history)
B = bleeding (history or predisposition)
L = labile INR
E = Elderly (65+)
D = Drugs (antiplatelets/NSAIDs) and alcohol (excess) - 1pt each

Question 15

What is the follow-up procedure for someone with AF?

Answer 15

Regular (6-12 month) follow up ECGs +/- stress testing

Regular ECG testing for any patient on an anti-arrhythmic agent

Regular monitoring of INR for patients on Warfarin