Atrial Fibrillation and Flutter Parts 1 and 2

Question 1

Afib definition

Answer 1

A muscular twitching involving individual muscle fibers acting without coordination
Loss of organized atrial activity (no P waves)
Irregularly irregular ventricular response

Question 2

Atrial flutter

Answer 2

Variable AV conduction

Organized atrial rhythm with a rate of 250-350 BPM due to a large re-entrant loop in the atria

Question 3

Time length of
1. Paroxysmal
2. Persistent
3. Long standing persistent
Afib

Answer 3

1. Episodes end < 7 days
2. Episodes > 7 days
3. Afib continually present > 12 months

Question 4

Symptoms of Afib

Answer 4

~50% have none at all
Palpitations
Dizziness
SOB
Chest pain
Presyncope/syncope
Fatigue
Decreased exercise tolerance

Question 5

4 ways to confirm afib diagnosis

Answer 5

12 lead ECG
24 hour Holter monitor
2 week event monitor
Implantable loop recorder

Question 6

Potential underlying/predisposing conditions for afib

Answer 6

Echo to check for valvular heart disease, hypertophy, random zebra things
TSH
CXR
CBC, lytes, glucose

Question 7

What associated condition/disease is a big concern with afib?

Answer 7

Stroke

Anticoagulation really important

Question 8

Calcium channel blockers

1. Non-dihydropyridine
2. Dihydropyridine

Answer 8

1. Diltiazem, verapamil

2. Nifedipine, amlodipine, felodipine

Question 9

What CCBs should you use for afib?

Answer 9

The non-dihydropyridines (diltiazem, verapamil)

Question 10

Tachy-Brady Syndrome

Answer 10

Rapid heart rate at times (often with exertion and causing symptoms)
Marked bradycardia or pauses at other times (most commonly a conversion pause between afib and normal sinus, may be very symptomatic)

Question 11

Treatment for Tachy-Brady Syndrome

Answer 11

Try different rate controlling medication
Consider rhythm control
Most often will need a pacemaker (prevents pauses)

Question 12

Control of heart rate

Answer 12

Leaves the heart fibrillating but uses meds (or procedures) to slow down the ventricular response
The goal is a resting HR < 100 beats/minute
Slower HR gives the ventricles more time to relax and fill with blood, and improves symptoms

Question 13

Control of rhythm

Answer 13

Medicines and/or procedures used to convert AF to a normal rhythm
Goal is to decrease how often episodes occur and how long they last
May not prevent all episodes of AF

Question 14

Factors that favour rate control

Answer 14

Persistent AF
Less symptomatic
Over 65
HTN
No history of CHF
Previous antiarrhythmic drug failure
Patient preference

Question 15

Factors that favour rhythm control

Answer 15

Paroxysmal AF
Newly detect AF
More symptomatic
Under 65
No HTN
CHF clearly exacerbated by AF
No previous antiarrhythmic drug failure
Patient preference

Question 16

First line agent for ventricular rate control

Answer 16

Beta blocker

The add digoxin, consider ablation

Question 17

Why do we pursue rhythm control?

Answer 17

Improved symptoms and QoL
Beneficial reverse remodelling
Possible mortality benefit
Potential reduced risk of stroke

Question 18

First line treatment (and why) for atrial flutter

Answer 18

Catheter ablation

Because HR control is difficult, and rhythm control drugs rarely work

Question 19

Rate control prevents what condition?

Answer 19

Heart failure

Question 20

Do symptomatic patients need rate or rhythm control?

Answer 20

Rhythm