Atrial Fibrillation

Question 1

What is atrial fibrillation?

Answer 1

• Cardiac arrhythmia characterised by an irregularly irregular rate
• Normal controlling timer in the heart overridden by random electrical impulses fired off
• Meaning atrium ‘quivers’ only partly contracts

Question 2

Acute AF meaning?

Answer 2

First onset within last 48hours

Question 3

Recurrent AF ?

Answer 3

Two or more episodes can be classified as recurrent. They can be paroxysmal or persistent

Question 4

Paroxysmal AF?

Answer 4

Spontaneous termination within7 days and often within 48hours

Question 5

Persistent AF?

Answer 5

Not self terminating, lasting longer than 7 days

Question 6

Permanent AF

Answer 6

Longstanding AF, longer than a year and cardio version unsuccessful

Question 7

What can trigger new AF or make it worse?

PIRATES

Answer 7

Pulmonary embolism
Ischaemia
Respiratory distress
Atrial enarglement or myxoma
Thyroid disease
Ethanol
Sepsis/sleep apnoea

Question 8

What can be the causes of AF?

Answer 8

Increased intracardiac pressure

• Idiopathic/lone AF
• Valvular heart disease
• Hypertension
• Congestive heart failure
• Left ventricular hypertrophy
• Atherosclerosis
• Obesity
• MI
• PE
• Hyperthyrodisim
• Pneumonia
• Caffeine
• Alcohol
• Post-op hypokalaemia/hypomagnesaemia

Question 9

What is the pathophysiology of AF?

Answer 9

1. Increased intracardiac pressure
2. Dilatation of the atria can lead to decrease in atrial muscle mass and fibrosis and the atrial muscle
3. Leads to areas of atrial muscle tissue which then generates random disorganised electrical impulses which override the organised impulses from the SAN
4. Leads to irregularly irregular ventricular rate

Question 10

What are the symptoms of AF?

Answer 10

• Asymptomatic
• Chest pain
• Palpitations
• Dyspnoea
• Faitness
• Anxiety

Question 11

What are the signs of AF?

Answer 11

• Irregularly irregular pulse
• First heart sounds of variable intensity
• Signs of Heart failure in worsening AF (bibasal creps, oedema)
• Signs of underlying cause

Question 12

What investigations should be done in AF?

Answer 12

• ECG
• Bloods: TFTs, U&Es, Cardiac enzymes
• Echocardiograme

Question 13

What will an ECG of AF show?

Answer 13

• Irregularly irregular
• Absent P waves
• Narrow QRS

Question 14

Management step of acute AF

Answer 14

1. A-E assessment
2. Treat precipitating factors
3. Assess patients stroke risk: CHA2DS2,VAS score and HAS BLED score = anticoagulation with LMWH
4. Acute rate control: beta-blockers or diltiazem/verapamil

Question 15

Management of paroxysmal AF

Answer 15

Flecainide PRN “pill in pocket”

Question 16

Management of chronic AF

Answer 16

Rate control

1. B-blockers and rate limiting Ca2+ blockers Diltiazem/verpamil
2. Consider amiodarone if not working

Rhythm control
3. Mechanical or pharmacological cardioversion =DC shock or IV flecainde or amiodarone

Anticoagulation

4. Apixaban to prevent secondary thromboembolic event
   - aim for INR 2-3