Atrial Fibrillation

Question 1

Outline the ECG findings in a typical counter-clockqwise atrial flutter

Answer 1

On the ECG, note the saw-
tooth shaped P wave,
negative in leads II, III, and
aVF, which indicates the
retrograde conduction up
the atrial septum,
consistent with counter-
clockwise flutter.

Question 2

there are 2 broad types of AFL

1. TYpical: negative F waves in __, ___ and ___ leads

• postivie F waves in ___
• counterlockwise reenntry around __

2. Atypical:

• other F wavemorphologies (ie____)
• ___ reentry around TVA
• reentry around other antaomic obstacles. Reentry around the __ __ ___, other circuits.

Answer 2

1. TYpical: negative F waves in II, III and avFleads
   - postivie F waves in V1
   - counterlockwise reenntry around TVA
2. Atypical:
   - other F wavemorphologies (ie/ F waves are positive in inferior leads and negative in V1)
   - clockwise reentry around TVA
   - reentry around other antaomic obstacles. Reentry around the mitral valve annulus, other circuits.

* F WAVES MEAN FLUTTER/FIB WAVES.

Question 3

Atrial flutter is rapid but REGULAR and organized atrial activity. The mechanism is:

Answer 3

reentry. initiation requires critically timed extra atrial beats. maintenance requires depolarizing wavefront to always encounter excitable tissue.

Question 4

Question 5

outline the ECG findings in the Atypical AFL

Answer 5

• probably clockwise around the TVA
• Fwaves are positive in the intfeiror leads and the negative in V1. (reverse of typical AFL, which has negative inferior leads (II, III, aVF)
• recall that atrial flutter usually is negative in II III avF (inferior leasd)

Question 6

how does catheter ablation help with atrial flutter

Answer 6

ablation in the tricuspid isthmus creates a line of block that interrupts the flutter circuit. Subsequent pacing from the coronary sinus demonstrates bi-directional block along the line of ablation

Question 7

atrial fibrillation is a rapid, ____ and even chaortic form of atrial tachyarrhthmia with an _____ ventricular repsonse.

Answer 7

atrial fibrillation is a rapid, irregular and even chaortic form of atrial tachyarrhthmia with an IRREGULAR ventricular repsonse. the poor atrial function is causing irregular ventricular function too.

Question 8

outline Afibrillation on ECG

Answer 8

lack of P waves

• irregular atrial activity
• irregularity of QRS complex
• Note; in atrial flutter, the sinus beat is still normal. Here, the QRS complex is just changing all the tiem.

Question 9

AF causes an irregular rapid atrial activity. On the ECG; there is inconcsistent p wave rate and morphology .

with AV conduction: irregularly irregulay ventricular repsonse. Usually it’s fast but can be slow if disease or drugs prolong the AVN refractory period.

With a complete AV block: ventricular rate is dependen on the __ __, and is ___.

Answer 9

AF causes an irregular rapid atrial activity. On the ECG; there is inconcsistent p wave rate and morphology .

with AV conduction: irregularly irregulay ventricular repsonse. Usually it’s fast but can be slow if disease or drugs prolong the AVN refractory period.

With a complete AV block: ventricular rate is dependen on the escape rhythm, and is regular.

Question 10

important “risk factors” that contribute to likelithood of Afib

Answer 10

• Age (5% of octogenarians)
• Hypertension
• Hyperthyroidism*
• Mitral valve disease
• Any heart disease
• Lung disease
• Obstructive sleep apnea (OSA)
• Surgery*, especially cardiac surgery because of the high chatecholamine amounts
• Alcohol (“Holiday Heart Syndrome”)
• High vagal tone • Others . . .

Question 11

when is it normal for someone to have lone AF

Answer 11

• 20 year old healthy people
• children
• marathon runners

Question 12

3 classifications of how atrial fibrillations is categorized

Answer 12

1. paroxysmal
2. persistent
3. permanent.

Question 13

tachy-brady syndrome

Answer 13

• combination of paroxysmal atrial fibrillation and bradycardia at other times.
• usually sinus bradycardia or sinus pauses at the termination of AF.

Question 14

treatments for tahcy-brady syndrome

Answer 14

Rate slowing drugs or antiarrhythmic drugs are
required to treat the “tachy” component (the AF).
These will all worsen the sinus node dysfunction.’

• A permanent pacemaker is required to manage
the “brady” component

Question 15

symptoms of AF/AFL

Answer 15

Symptoms of AF/AFL

• *• Palpitation, dyspnea (including chest
  pressure) , fatigue (no energy)**
  1. Ventricular response is too fast

2. Ventricular response is irregular
3. Loss of atrial “kick”
   • No symptoms at all.
   – Some people are never symptomatic, and others
   are sometimes symptomatic. – TIA or stroke can be the first manifestation of
   AF(L) (and pt may be in SR or AF(L) when they
   have the stroke).

Question 16

physical findings of AF

Answer 16

irregularly irregular pulse rate and volume (often rapid)

• variable intensity of first heart sound

- no S4.

• when the patient also has a systolic murmur; it could be due to MR or stenosis
• constant intensity== regurgitent
• variable intensirty murmur = ejection (AS, stenosis)

Question 17

consequences of AF/L

Answer 17

Question 18

T/F: You gotta watch for a lot of dyspnea in someone with AF because of the likelihood of pulmonar embolism.

Answer 18

FALSE. pulmonary embolism is not a consequence of AFL. BUT pulmonar embolism can trigger AF.

• stiil you should watch for dyspnea regardless

Question 19

4 steps to treatment of AFL

Answer 19

1. consider anticoagulation
2. consider underlying cauases
3. consider rate control or rhythm control
4. consier anticoagulation (again)

Question 20

types of anticoagulants that can be considered for AFL treatment

Answer 20

• warfarin (INRR 2-3)
• DOACS; dabigatran, apixaban, rivaroxban, edoxaban.
• you must consider the risk of embolic stroke form AF vs hemorrhagic stroke (from anticoagulation)

- people with moderate to severe mitral stenosis or mechanical heart valves are at high risk for stroke– ONLY USE warfain.DO NOT GIVE DOAC– severe mitral stenosis or mechanical heart valve are aka “valvular AF”

valvular AF; mitral stenosis and mechanical heart valve. THIS IS NOT THE SAME IF THEY HAVE AORTIC STENOSIS. ONLY MITRAL STENOSIS CAUSES VALVULAR AF.

Question 21

T/F blood testing monitoring is required for DOACs/NOACS

Answer 21

false. the pro about doacs is that they dont need to be continuously monitored.

Question 23

“valvular AF”

Answer 23

people with mitral stenosis (NOT ANY OTHER TYPE OF VALVE STENOSIS) or mechanical heart valves.

Question 24

note; remember hthe CHAD65 acronym for OAC therpay in AF.

note the Aspirin does not prevent stroke. the aspirin is reccommended to prevent vascular events.

Question 25

underlying causes of AF **(PAV**)

Answer 25

- hypertension **(pressure)** - alcoholism **(vodka)** - obstructive sleep apnea **(apnea)** - PE. AFL alone is not.a reason to order a CT scan to r/o pe thouhg. - everyone should get histoyr and physical, TSH and echo.

Question 26

**Rate Control:** Let AF happen when it happens, or let it be permanent . . . Just make sure the ventricular response to AF isn’t too fast (ie. prolong AVN refractory period: __ blockers, ___ channel blockers, \_\_\_). **Rhythm Control:** Prevent AF and maintain normal sinus rhythm [true antiarrhythmic drugs(AAD’s): sotalol, \_\_, __ +/- \_\_]

Answer 26

Rate Control: Let AF happen when it happens, or let it be permanent . . . Just make sure the ventricular response to AF isn’t too fast (ie. prolong AVN refractory period: **beta** blockers, **calcium** channel blockers, **digoxin- Digoxin induces an increase in intracellular sodium that will drive an influx of calcium in the heart and cause an increase in contractility.**). Rhythm Control: Prevent AF and maintain normal sinus rhythm [true antiarrhythmic drugs(AAD’s): **sotalol**, **propafenone**, **amiodarone** +/- **cardioversion**]

Question 27

treatment for first episode of AFL

Answer 27

after cardioconversion, wait and see. it could be years before next one.

Question 28

for rate control, digoxin alone is useless. what else shold be used?

Answer 28

digoxin alone is useless, but useful as an adjunct to BB or CCB (calcium channel blocker)

Question 29

ultimate rate controlling procedure if drugs fail

Answer 29

cauterize the AV node and create the heart block. ONce the AV node is ablated, the pacemaker that was inserted continues to run the rhythm. ## Footnote **indicated for paroxysmal or permanent atrial flutter.**

Question 30

non drug treatment strategy for rhythm control of AF/L

Answer 30

**1. Pulmonary vein isolation**. using the ablation catheter in the leedt anterior oblique to cauterize the pulmonary veins. - around 60% will have resolution of atrial fibrilltion. **2. Ablation of the AV node** also would help for rhythm control.

Question 31

outline some rhythm control drugs

Answer 31

There's class III, IC, and IA.

Question 32

largest age demographic affected by atrial fibrillation

Answer 32

usually middle age around 60-80.

Question 33

torsades de points: Torsades de pointes is a specific form of polymorphic ____ tachycardia in patients with a long ___ interval. It is characterized by rapid, irregular ____ complexes, which appear to be twisting around the electrocardiogram (ECG) baseline

Answer 33

torsades de points: Torsades de pointes is a specific form of polymorphic VENTRICULAR tachycardia in patients with a long QT interval. It is characterized by rapid, irregular QRS complexes, which appear to be twisting around the electrocardiogram (ECG) baseline

Question 34

What type of atrial flutter is this ECG consistent in?

Answer 34

**_Atrial Flutter: Typical counter-clockwise atrial flutter_** On the ECG, note the saw- tooth shaped P wave, negative in leads II, III, and aVF, **which indicates the retrograde conduction up the atrial septum**, consistent with counter- clockwise flutter.

Question 35

NOTE: In **atrial fibrillation,** the atria beat **irregularly**. In **atrial flutter,** the atria beat **regularly**, but **faster** than usual and more often than the ventricles, so you may have four atrial beats to every one ventricular beat. can kinda be treated the same way though.

Question 36

associative conditions/comorbidities that can be linked with atrial flutter.

Answer 36

Question 37

patients with atrial flutter may have no symptoms at all. What is the first presentation/manifestation of asymptomatic atrial flutter/fibrillation?

Answer 37

Some people are never symptomatic, and others are sometimes symptomatic. – **TIA or stroke** can be the first manifestation of AF(L) (and pt may be in SR or AF(L) when they have the stroke).

Question 38

What heart sound will always be absent in someone with AF

Answer 38

S4 is impossible S4 is usually because of thickened ventricle/distended ventricle. It is caused by **vibration of the ventricular wall during atrial contraction. This sound is usually associated with a stiffened ventricle** (low ventricular compliance), and therefore is heard in patients with ventricular hypertrophy, myocardial ischemia, or in older adults The fourth heart sound (S4), also known as the"atrial gallop", occurs just before S1 **when the atria contract to force blood into the LV.** During atrial fibrillation, **contraction of the left atrium is lost** and **thus an S4 heart sound can't be present**

Question 39

You should consider anticoagulation in someone with AF/L in order to prevent complications like TIAs. In what group should you consider giving warfarin?

Answer 39

people with moderate to **severe mitral stenosis or mechanical hear**t (those with valvular AF) valves are at high risk for stroke-- **maybe use warfain**. **NO DOACS.**-- severe mitral stenosis or mechanical heart valve are aka "valvular AF"

Question 40

T/F Stroke risk in someone with pre-existing AF is dependent on current rhythm of the heart.

Answer 40

``` false. Timing of embolic stroke not related to being in AF(L) or timing of AF(L) ```