Atrial Fibrillation and Flutter

Question 1

Paroxysmal atrial fibrillation

Answer 1

Self-termination within 7 days (includes those cardioverted within 7 days).

Question 2

Persistent atrial fibrillation

Answer 2

Continuous atrial fibrillation lasting longer than 7 days.

Question 3

Long-standing persistent atrial fibrillation

Answer 3

Continuous atrial fibrillation lasting longer than 12 months.

Question 4

Permanent atrial fibrillation

Answer 4

Term used when decision is made to stop further attempts to restore and/or maintain sinus rhythm.

Question 5

Consider adjunctive use of ___ when able prior to electrical cardioversion

Answer 5

Amiodarone.

Question 6

Pre-procedure anticoagulation is not required prior to cardioversion for those who have been in Afib for less than ___.

Answer 6

48 hours.

Question 7

Individuals who have been in atrial fibrillation for greater than ___ must anticoagulate for at least ___ prior to DCCV (or a TTE must be obtained).

Answer 7

48 hours.

3 weeks.

Question 8

All individuals should anticoagulate for at least ___ following DCCV due to risk of myocardial stunning.

Answer 8

4 weeks.

Question 9

Management of atrial fibrillation in tachycardic but otherwise hemodynamically stable patients:

Answer 9

1. Beta-blockers (metoprolol, labetalol, propranolol, esmolol).
2. Calcium channel blockers (diltiazem, verapamil).
   * Start with IV, then follow with PO.

Question 10

Management of atrial fibrillation in tachycardic but hemodynamically tenuous patients:

Answer 10

1. Low-dose beta-blocker or calcium channel blocker.
2. Digoxin load (contraindicated with accessory pathways).
3. Amiodarone bolus/load.

Question 11

Management of atrial fibrillation in tachycardic and hemodynamically unstable patients:

Answer 11

1. DCCV.

2. Phenylephrine (causes reflex bradycardia).

Question 12

___ blockers are more successful than ___ blockers at achieving rate control.

Answer 12

1. Beta.

2. Calcium channel.

Question 13

Digoxin is effective at rate control only with ___.

Answer 13

Rest. Not effective when the patient is exerting themselves.

Question 14

Long-term digoxin is associated with ___ in atrial fibrillation patients.

Answer 14

Increased mortality.

Question 15

Target rate in patients with atrial fibrillation:

Answer 15

<110 bpm, which has been shown to be non-inferior to stricter rate control (HR <80 bpm).

Question 16

Calcium channel blockers should be avoided in patients with an EF

Answer 16

40%.

Question 17

First-line antiarrhythmic in patients with pre-excitation on EKG:

Answer 17

Procainamide.

Question 18

Long-term rhythm control in patients with CAD:

Answer 18

1. Dofetilide.
2. Dronedarone.
3. Sotalol.
4. Amiodarone.

Question 19

Long-term rhythm control in patients with CHF:

Answer 19

1. Amiodarone.

2. Dofetilide.

Question 20

Long-term rhythm control in patients with LVH:

Answer 20

1. Amiodarone.

2. Dofetilide.

Question 21

Long-term rhythm control in patients with no structural heart disease:

Answer 21

1. Flecainide/propafenone.
2. Dofetilide.
3. Dronedarone.
4. Sotalol.
5. Amiodarone.

Question 22

Options for chemical cardioversion:

Answer 22

1. Flecainide/propafenone.
2. Dofetilide.
3. Ibutilide.
4. Amiodarone.

Question 23

Components of the CHADS2-VASc score:

Answer 23

CHF (1)
HTN (1)
Age 65-74 (1)
DM (1)
Female sex (1)
Vascular disease (1)
Age >75 (2)
Stroke/TIA (2)

Question 24

Management of CHADS2-VASc of 0:

Answer 24

No anticoagulation.

Question 25

Management of CHADS2-VASc of 1:

Answer 25

No anticoagulation vs ASA vs anticoagulation.

Question 26

Management of CHADS2-VASc of 2+:

Answer 26

Anticoagulation.

Question 27

HAS-BLED score components:

Answer 27

``` HTN (SBP >160) (1) Abnormal renal/hepatic function (CrCl <50, Cirrhosis, Bili >2x ULN, AST/ALT/ALP >3x ULN) (1) Stroke (1) Bleeding history (1) Labile INR (<60% in Rx range) (1) Elderly (>65 years) (1) Drugs (ASA, NSAIDs, EtOH) (1) ```

Question 28

HAS-BLED score greater than ___ should prompt closer monitoring in the outpatient setting.

Answer 28

3.

Question 29

Rate control options for atrial flutter:

Answer 29

Beta-blockers and calcium channel blockers. More difficult to successfully control than atrial fibrillation.

Question 30

Rhythm control options for atrial flutter:

Answer 30

Cavo-tricuspid isthmus (CTI) ablation for type 1 (typical) flutter. >90% effective at one year.

Question 31

Anticoagulation guidelines for atrial flutter:

Answer 31

Treat like atrial fibrillation.

Question 32

Characteristics of counterclockwise flutter waves:

Answer 32

Inverted in II, III, and aVF. Upright in V1.

Question 33

Characteristics of clockwise flutter waves:

Answer 33

Upright in II, III, and aVF. Inverted in V1.