Atrial Fibrillation

Question 1

What is the result of dilatation on the atria?

Answer 1

progressive fibrosis

Question 2

How is diagnosis confirmed?

Answer 2

ECG: irregular PR intervals & absent p waves

Question 3

What should be arranged if paroxysmal AF is suspected, but AF is not detected on ECG?

Answer 3

Arrange an ambulatory ECG

Question 4

What are the 4 classes of AF?

Answer 4

1. Paroxysmal
2. Persistent
3. Long-standing persistent
4. Permanent

Question 5

Define paroxysmal AF

Answer 5

Recurrent >2 episodes that terminate within 7 days (or <48 hours terminated with CV)

Question 6

Define persistent AF

Answer 6

Continuous >7 days or >48 with CV

Question 7

Long-standing persistent AF

Answer 7

Continuous, lasting >12 months

Question 8

Permanent AF

Answer 8

Abnormal heart rhythm can’t be restored. Joint decision to cease further attempts of restoring sinus rhythm

Question 9

Which 3 cardiac conditions is AF most commonly associated with?

Answer 9

HTN
CHD
MI

Question 10

Give 5 non-cardiac causes

Answer 10

Infection
Autonomic neuronal dysfunction
Electrolyte imbalance
Cancer
Hyperthyroidism

Question 11

Which two electrolyte imbalances can cause AF?

Answer 11

Hypokalaemia & hyponatraemia

Question 12

What two drinks can exacerbate AF?

Answer 12

Caffeine & alcohol

Question 13

How is stroke risk assessed in primary care?

Answer 13

CHA2DS2VASc assessment tool

Question 14

What makes up chadvasc?

Answer 14

Congestive HF
HTN
Age >75
Diabetes
Stroke/ TIA
Vascular disease
Age 65-74
Sex (female)

Question 15

Based on chadvasc score, when is anticoagulant treatment indicated?

Answer 15

If score is >2

or consider in men with a score of >1

Question 16

What is HAS-BLED?

Answer 16

An assessment of the risk of a major bleed (scored out of 9)

Question 17

what are the 2 principles of AF management?

Answer 17

ANTICOAGULATION

RATE CONTROL

Question 18

What should be given as an anticoagulant?

Answer 18

NOAC: apixiban, rivaroxaban
OR
VITAMIN K ANTAGONIST: warfarin

Question 19

What is a benefit of a NOAC over warfarin

Answer 19

Easily reversibly + does not require regular monitoring

Question 20

What is first line for rate control?

Answer 20

Beta blocker: BISOPROLOL

Question 21

What is an alternative first line of rate control to a beta blocker?

Answer 21

CCB (e.g. diltiazem)

Question 22

What is the only occasion digoxin would be indicated?

Answer 22

Only if non-paroxysmal and patient is SEDENTARY

Question 23

After starting rate control, how soon should a patient be followed-up?

Answer 23

Follow up after one week

Question 24

If symptoms are not controlled by combination treatment, what should you do?

Answer 24

Promptly refer to cardiology

Question 25

How should warfarin be monitored?

Answer 25

Initially monitor INR daily until it is 2-3 on two consecutive occasions, then monitor twice weekly for 1-2 weeks

Question 26

If onset of AF was within the last 48 hours, how should it be managed?

Answer 26

Urgently admit to AMU for cardioversion if there are signs of haemodynamic instability

Question 27

What are the signs of haemodynamic instability?

Answer 27

``` HR >150 Low BP Increaseing SOB Severe dizziness or syncope Ongoing chest pain ```