Atrial Fibrillation

Question 1

What does Cardioversion do?

Answer 1

Brings sinus rhythm back to normal

Question 2

What drugs can be used to achieve Pharmacological Cardioversion?

Answer 2

IV/Oral Amiodarone or Flecainide

Question 3

How is New Onset AF w/ Life Threatening Haemodynamic Instability treated?

Answer 3

Immediate electrical cardioversion w/o delay in using anticoagulants.

Question 4

What drugs can be used for Urgent Rate Control

Answer 4

IV Beta Blockers or Verapamil

Question 5

How is AF w/o Life Threatening Haemodynamic Instability treated? (2 answers depending on AF onset time)

Answer 5

Onset <48 hours: Rate or Rhythm

Onset >48 hours: Rate is preferred

Question 6

How long do Anticoagulants need to be given for in patients who are offered non-immediate (+ onset > 48 hours) electrical cardioversion?

Answer 6

At least 3 Weeks Before Cardioversion, and continued for at least 4 Weeks After Cardioversion.

Question 7

When is Rate Control NOT used as 1st line therapy?

Answer 7

• New Onset AF
• Atrial Flutter is suitable for ablation surgery
• Reversible AF
• Rhythm Control is more clinically suitable

Question 8

State the drugs that can be used for Rate Control?

Answer 8

Beta Blockers (Except Sotalol), Verapamil, Diltiazem (Unlicensed), Digoxin.

Question 9

Who can Digoxin be particularly used for?

Answer 9

Sedentary patients, as Digoxin controls ventricular rate at rest (usually for non-paroxysmal pts), it can also be used as rhythm control therapy in patients who have AF + Heart Failure.

Question 10

If Rate Control Monotherapy is not enough, what combinations of drugs can be used for Dual Therapy instead?

Answer 10

Beta Blocker, Digoxin and Diltiazem

Question 11

If ventricular function has diminished, which rate control dual therapy is preferred?

Answer 11

Digoxin + Beta Blocker

Question 12

When is Rhythm Control used and what is its purpose?

Answer 12

Used when:
- Rate control isn’t working
- Rhythm control is clinically more suitable
Purpose = To maintain sinus rhythm, usually after cardioversion.

Question 13

What are the 2 types of drugs which can be offered for Rhythm Control?

Answer 13

1) Standard Beta Blocker (not including Sotalol)
2) Anti-Arrhythmic Drugs:
- Flecainide
- Propafenone
- Amiodarone
- Dronedarone
- Sotalol

Question 14

What is the drug pathway for Rhythm Control post cardioversion?

Answer 14

1st offer Standard Beta Blocker (not including Sotalol), if this is ineffective then oral anti-arrhythmic can be offered.

Question 15

What is Paroxysmal AF?

Answer 15

AF that is self-limiting (goes in 48 hours in the absence of treatment).

Question 16

When can Flecainide and Propafenone NOT be used?

Answer 16

Ischaemic or Structural Heart Disease

Question 17

How is Amiodarone given if used with electrical cardioversion?

Answer 17

Start Amiodarone from 3 Months Before and continued for up to 12 Months After electrical cardioversion.

Question 18

What is Persistent AF?

Answer 18

Lasts for >7 days and/or would need to cardioversion to restore sinus rhythm.

Question 19

What drug can be used w/ Left Ventricular Impairment or Heart Failure.

Answer 19

Amiodarone

Question 20

Describe what kind of therapy can be offered to certain patients who suffer from infrequent episodes of paroxysmal AF?

Answer 20

Pill in the pocket therapy - Patient takes oral Flecainide or Propafenone to self treat whenever episode occurs.

Question 21

What is the drug pathway for Paroxysmal AF?

Answer 21

1st offer Standard Beta Blocker (not including Sotalol), if this is ineffective then oral anti-arrhythmic such as, Flecainide, Propafenone, Sotalol or Amiodarone can be offered.

Question 22

Give examples of how Anti-Arrhythmic drugs like Flecainide and Propafenone have limited use in Atrial Flutter?

Answer 22

They can slow atrial flutter so a rate controlling drug e.g. standard beta blocker, verapamil or diltiazem needs to be prescribed.

Question 23

When can Amiodarone be considered for Atrial Flutter?

Answer 23

If all other drugs are ineffective or contraindicated.

Question 24

What pneumonic is used to assess need for anticoagulation? What does each letter stand for and what are the corresponding points?

Answer 24

CHA2DS2-VASc
C = Congestive Heart Failure (1)
H = Hypertension (1)
A = Age =/> 75 (2)
D = Diabetes (1)
S = Stroke, Thromboembolism (2)
V = Vascular Disease (1)
A = Age 65-74 (1)
Sc = Sex Category - Female (1)

Question 25

What CHA2DS2-VASc Scores do NOT require Anticoagulation Treatment for men and women?

Answer 25

Low risk for men = 0
Low risk for women = 1
(so anticoagulant only required if men >0 and women >1)

Question 26

What pneumonic is used to assess likelihood of bleeding from taking Anticoagulants? What does each letter stand for and what are the corresponding points?

Answer 26

HAS-BLED
H = Hypertension (1)
A = Abnormal Liver/Renal Function (1 or 2)
S = Stroke (1)
B = Bleeding Incident (1)
L = Labile INR (1)
E = Elderly =/> 65
D = Drugs/Alcohol (1 or 2)

Question 27

What 4 factors of HAS-BLED are modifiable and how can this be useful?

Answer 27

Hypertension, Drugs, Alcohol, Labile INR
If a patient’s HAS-BLED score is high, we can try reducing their risk of bleeding by altering these factors, e.g. changing the meds they’re on, controlling their BP, etc.

Question 28

Which drug should NOT be used as Monotherapy to Prevent Stroke?

Answer 28

Aspirin

Question 29

What are the 2 different types of Anticoagulants? (Give examples of each type)

Answer 29

1) Vitamin K Antagonist
- Warfarin
2) NOACs
- Apixaban
- Dabigatran
- Rivaroxaban

Question 30

What is Torsade De Pointes?

Answer 30

Ventricle Tachycardia associated w/ prolonged QT levels

Question 31

What can cause prolonged QT in TdP?

Answer 31

• Drugs
• Hypokalemia
• Severe Bradychardia

Question 32

How is TdP usually treated?

Answer 32

Intravenous Infusion of Magnesium Sulfate

Question 33

What drugs can NOT be used in TdP and why?

Answer 33

Anti-Arrhythmic Drugs e.g. Flecainide, Sotalol, Propafenone, Amiodarone, etc.
Because they prolong QT interval so would worsen condition.