Atrial Fibrillation/Flutter

Question 1

What is atrial fibrillation?

Answer 1

Chaotic + disorganised atrial activity

–> irregularly irregular heart beat

Question 2

What causes AF?

Answer 2

Ectopic foci in muscle sleeves in ostia of pulmonary veins

Question 3

What are the 3 options for termination of AF?

Answer 3

• spontaneous reversion to sinus rhythm
• pharmacological cardioversion
• DCCV

Question 4

What are the 3 types of AF?

Answer 4

Paroxysmal
Persistent
Permanent (chronic)

Question 5

How is paroxysmal AF defined?

Answer 5

Acute onset, lasts < 48 hours

Often recurrent

Question 6

How is persistent AF defined?

Answer 6

An episode lasting > 48 hours which can still be cardioverted to NSR
Unlikely to spontaneously revert to NSR

Question 7

How is permanent AF defined?

Answer 7

Inability to restore NSR with pharmacological or non-pharmacological methods

Question 8

What are some of the symptoms of AF?

Answer 8

Palpitations
Chest pain
Syncope/pre-syncope
SOB
Sweatiness
Fatigue

–> symptoms often worse at the onset of AF

Question 9

What are the ECG features in AF?

Answer 9

• atrial rate > 300 (atria quiver, not contract)
• irregularly irregular rhythm
• ventricular rate variable
• absent P waves
• presence of ‘f’ waves

Question 10

Which factors affect the ventricular rate in AF?

Answer 10

• AV node conduction properties
• sympathetic/parasympathetic tone
• presence of drugs acting on the AV node (e.g. beta-blockers, CCBs)

Question 11

What are the three main approaches to management of AF?

Answer 11

Rhythm control –> maintain SR
Rate control –> accept AF but control ventricular rate
Anticoagulation –> prevent thromboembolism

Question 12

How does rate control work in AF?

Answer 12

Slows AVN conduction

Question 13

What are the options for rate control drugs in AF?

Answer 13

Beta-blocker or CCB (Verapamil, diltiazem) first line

Digoxin in patients who live sedentary lifestyle e.g. elderly

Question 14

What are the options for pharmacological cardioversion in AF?

Answer 14

Amiodarone

Flecainide

Question 15

What are the options for maintenance of normal SR in AF?

Answer 15

• Beta-blocker
• Flecainide, sotalol or amiodarone
• Catheter ablation of atrial focus
• Surgery –> Maze procedure

Question 16

How do you assess the need of anticoagulation in AF?

Answer 16

CHA2DS2VASc score

Question 17

What are the components of the CHA2DS2VASc score?

Answer 17

C - congestive HF/LV dysfunction
H - hypertension
A2 - age 75 or over
D - diabetes
S2 - stroke (TIA/TE)
V - vascular disease
A - age 65-74
S - sex female

Question 18

Which other factors (outwith the CHA2DS2VASc score) are a strong indication for anticoagulation in AF?

Answer 18

Thyrotoxicosis
Hypertrophic cardiomyopathy
Valvular AF - mitral stenosis/regurgitation

Question 19

What is the choice of anticoagulant in AF?

Answer 19

Warfarin

- if non-valvular AF, DOAC can be used

Question 20

What is atrial flutter?

Answer 20

Rapid, regular form of atrial tachycardia

Usually paroxysmal

Question 21

What is the classic ECG finding in atrial flutter?

Answer 21

Classic ‘saw tooth’ baseline

Question 22

What is usually the atrial rate in atrial flutter?

Answer 22

300 bpm

Question 23

What is usually the ventricular rate in atrial flutter?

Answer 23

150 bpm

Question 24

What are the main treatment options in atrial flutter?

Answer 24

Cardioversion
Drugs to:
- slow ventricular rate
- restore sinus rhythm
- maintain sinus rhythm 
RF ablation
Warfarin to prevent thromboembolism