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Y3(M) - Cardiology > Atrial Fibrillation + Heart Failures > Flashcards

Atrial Fibrillation + Heart Failures Flashcards

1
Q

What is atrial fibrillation?

A

Disorganised electrical activity in the atria leads to an irregularly irregular pulse

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2
Q

What effects can atrial fibrillation have on the body?

A

Irregularly irregular ventricular contractions
Tachycardia
Heart failure
Increased stroke risk

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3
Q

Why can heart failure occur with atrial fibrillation?

A

Impaired filling of the ventricles in diastole since the atria and ventricles spend less time in diastole

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4
Q

Why are patients at an increased risk of stroke with atrial fibrillation?

A

Impaired emptying of the atria into the ventricles leading to stasis of blood (time in diastole is less) leads to coagulation of blood which can exit via the carotid arteries

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5
Q

How are ventricular contractions (QRS) affected by atrial fibrillation?

A

Irregularly irregular ventricular contraction:

The chaotic rapid irregular atrial electrical actiivty overrides the organisation by the SAN

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6
Q

What is the mnemonic used to remember the most common causes of Atrial fibrillation?

A

SMITH

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7
Q

What are the most common causes of atrial fibrillation?

Use the mnemonic

A

SMITH

S - Sepsis
M - Mitral valve issues (stenosis or regurgitation)
I - Ischaemic Heart Disease
T - Thyrotoxicosis
H - Hypertension

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8
Q

What are some lifestyle causes of atrial fibrillation?

A

Alcohol
Caffeine

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9
Q

How may a patient with atrial fibrillation present?

A

Palpitations
SOB
Dizziness/SYNCOPE
Symptoms of common causes of atrial fibrillation (SMITH)

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10
Q

How can you exclude ventricular ectopics as a differential for atrial fibrillation?

A

When having ECG monitoring , when exercise occurs (inc heart rate) the ventricular ectopics will disappear

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11
Q

What ECG changes are found on an ECG showing atrial fibrillation?

A

Absent P waves
Irregularly irregular ventricular rhythm (QRS)
Narrow QRS complex tachycardia

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12
Q

What is paroxysmal Atrial fibrillation?

A

Episodes of atrial fibrillation that reoccur and spontaneously resolve back to sinus rhythm

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13
Q

How do you investigate a potential paroxysmal atrial fibrillation?

A

Normal ECG
If normal ECG negative do:
-24hr ambulatory ECG
-Cardiac event recorder (1-2wks)

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14
Q

What is valvular atrial fibrillation?

A

AF with significant mitral stenosis or mechanical heart valve

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15
Q

What is non-valvular atrial fibrillation?

A

AF without valve pathology or valve pathology that is not mitral stenosis

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16
Q

What are the 2 categories of mediations for treating atrial fibrillation?

A

Rate or rhythm control
Anticoagulation

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17
Q

What medications are most patients with atrial fibrillation put on?

A

Bisoprolol
Apixaban or rivaroxaban.

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18
Q

What is the purpose of giving Bisoprolol or a CCB in managing atrial fibrillation?

A

Reduce the heart rate to increase the amount of time in diastole so ventricles can more efficiently fill with blood

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19
Q

When are rate control medications not the first line medication for treating atrial fibrillation?

A

Reversible cause of AF
New onset atrial fibrillation. (Within last 48hrs)
Heart failure due to AF
Symptoms despite effective rate control

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20
Q

What classes of mediations are suitable for rate control when managing an atrial fibrillation?

A

Beta blocker = first line (bisoprolol or atenolol)

CCB (diltiazem or verapamil)

Digoxin

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21
Q

What patients can CCB like diltiazem or verapamil not be recommended for with atrial fibrillation?

A

Patients with heart failure

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22
Q

What are the 2 strategies for rhythm control for atrial fibrillation?

A

Cardio version
Long term rhythm control medications

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23
Q

When can rhythm control be offered to patients with atrial fibrillation?

A

Reversible cause of AF
New onset atrial fibrillation. (Within last 48hrs)
Heart failure due to AF
Symptoms despite effective rate control

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24
Q

When do you do immediate cardioversion for a patient with atrial fibrillation?

A

Atrial fibrillation has been present for less than 48hrs

Causing life threatening haemodynamic instability

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25
Q

What are the 2 options for cardioversion?

A

Pharmacological cardioversion
Electrical cardioversion

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26
Q

What are the pharmacological options for cardioversion?

A

Flecainide
Amiodarone

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27
Q

What situation would you choose amiodarone over flecainide to pharmacologically cardiovert a patient?

A

When the patient has structural heart disease

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28
Q

When is delayed cardioversion carried out for atrial fibrillation?

A

AF present for more than 48hrs and the patient is stable

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29
Q

What medications are given to a patient before delayed cardioversion?

A

Anti-coagulation like Apixaban and rivaroxaban 3 weeks before
Rate control like bisoprolol

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30
Q

Why are patients anticoagulated before delayed cardioversion when they have AF and are stable?

A

Clot could’ve formed and returning them back into sinus rhythm could send off the clot

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31
Q

What medications can be given for rhythm control with atrial fibrillation?

A

Beta blockers
Dronedarone
Amiodarone (HF or LV dysfunction)

32
Q

What is the management for paroxysmal atrial fibrillation?

A

Pill in the pocket approach

Flecainide pill taken when symptoms

Anticoagulation

33
Q

What is the option for a patient with atrial fibrillation if drug control for rate and rhythm is not adequate or tolerable?

A

Ablation

34
Q

What are the 2 types of ablation done if medications aren’t suitable for atrial fibrillation control?

A

Left atrial ablation
AVN ablation and permanent pacemaker

35
Q

What are the 2 types of anticoagulation that can be offered to patients with atrial fibrillation?

A

DOACs (apixaban or rivaroxaban)
Warfarin (if DOACs contraindicated)

36
Q

What must be done if a patient has a fall and they are anticoagulated?

A

CT head

37
Q

What are some DOACs that are often used in atrial fibrillation?

How do they work?

A

Apixaban
Rivaroxaban (Factor Xa inhibitors)
Edoxaban

Dabigatran (direct thrombin inhibitor)

38
Q

What is the reversal agent for apixaban or rivaroxaban?

A

Andexanet alfa

39
Q

What is the reversal agent for dabigatran?

A

Idarucizumab

40
Q

What are the advantages of DOACs like apixaban over warfarin?

A

Doesnt need INR monitoring
No major interactions
Same or better than warfarin
Same or lower bleed risk than warfarin

41
Q

How does Warfarin work?

A

Vitamin K epoxide reductase inhibitor

42
Q

What are the issues with Warfarin?

A

Needs close INR monitoring since it increases the prothrombin time
INR can fluctuate making patient more likely to have clots or bleed
Many drugs like antibiotics affect its metabolism by CYP450s in the liver (cranberry juice, alcohol)
Leafy green veggies make it not work as well

43
Q

What is the reversal agent of warfarin?

A

Active vitamin K and/or Prothrombin complex concentrate

44
Q

What is the screening tool used to decided whether patients with atrial fibrillation should receive anti-coagulation?

A

CHA2DS2-VASc

45
Q

What is CHA2DS2-VASc?

A

Mnemonic to remember the scoring factors suggesting a patient should start anticoagulation with atrial fibrillation

46
Q

What does the mnemonic CHA2DS2-VASc stand for?

A

The risk factors that score a point for needing Anticoagulation in AF

C - Congestive heart failure
H - Hypertension
A2 - Age > 75 (scores 2)
D - Diabetes
S2 - Stroke or previous TIA (scores 2)
V - Vascular disease
A - Age 65 - 74
S - Sex (Female)

47
Q

What are the results of scores from the CHA2DS2-VASc for Anticoagulation consideration?

A

0 = no anticoag
1 = consider anticoagulation in men (not women since women automatically score 1)
2 + = GIVE ANTICOAGULATION

48
Q

What is the scoring system used to assess a patients bleeding risk before giving anticoagulants?

A

ORBIT score
HAS-BLED

49
Q

What is chronic heart failure?

A

Clinical features of impaired heart function specifically the left ventricle reducing cardiac output, tissue hypoperfusion, increased pulmonary pressures and tissue congestion

50
Q

What respiratory issue often arises due to chronic heart failure?

A

Pulmonary oedema

51
Q

Why does pulmonary oedema occur with heart failure?

A

Increased volume and pressure of blood in the left ventricle backs up to the atrium then into the pulmonary veins and the lungs

52
Q

What are the 2 classes of heart failure?

A

Heart failure with reduced ejeection (HFrEF)
Heart failure with preserved ejection fraction (HFpEF)

53
Q

How do you work out ejection fraction?

A

Stroke volume / End Diastolic Voluume

54
Q

What is considered a reduced ejection fraction?
HFrEF?

A

Ejection fraction < 40%

Stroke vol/EDV

55
Q

What is considered a preserved ejection fraction?

A

Ejection fraction > 50%

56
Q

What would the broad issue with the heart be if a patient has a reduced ejection fraction. (HFrEF)?

A

Ejection / emptying problem of the ventricles (systolic dysfunction)

57
Q

What would the broad issue with the heart be if a patient has a preserved ejection fraction. (HFpEF)?

A

Filling issue
Diastolic dysfunction.

58
Q

What typically causes heart failure with a reduced ejection fraction(HFrEF)?

A

Muscle walls thin and fibrosed
Chamber space enlarged
Abnormal Or uncoordinated contraction

59
Q

What typically causes heart failure with a preserved ejection fraction(HFpEF)?

A

Chambers to stiff
Ventricle walls to hypertrophied

60
Q

What are the overall conditions that cause heart failure?

A

Ischaemic Heart Disease
Valvular heart disease (AORTIC STENOSIS)
HTN
Arrhythmias (AF)
Cardiomyopathy

61
Q

What are the symptoms of chronic heart failure?

A

Breathlessness (worse by exertion)
Cough (pink white frothy sputum)
Orthopnoea
Paroxysmal nocturnal dyspnoea
Peripheral oedema
Fatigue

62
Q

What is orthopnoea?

A

Breathlessness when lying flat (how many pillows do you sleep with)

63
Q

What is paroxysmal nocturnal dyspnoea?

A

Patients wake at night with severe shortness of breath cough and wheeze

May feel suffocated and may walk around wanting fresh air

64
Q

What is the pathophysiology of paroxysmal nocturnal dyspnoea?

A

Lucid settles across large surface area of the lungs while sleep
While asleep respiratory centre in brain less responsive so RR doesn’t increase so patient can become more congested and hypoxic before they wake up feeling unwell

65
Q

What can you find on examination of a patient with chronic heart failure?

A

Tachycardia
Tachypnoea
HTN
Murmurs if caused by valvular disease
3rd heart sounds
Bilateral basal crackles (oedema)
Raised JVP
Peripheral oedema

66
Q

What investigations would you do for a patient who you think might have heart failure?

A

NT-proBNP
ECG
Echocardiogram
Bloods (Anaemia, renal function, thyroid, liver,lipids , diabetes)
CXR
Lung function tests

67
Q

What is the classification system for heart failure?

A

New York Heart Association Classifaction (NYHA)

68
Q

What are the classes of heart failure according to the NYHA classification?

A

Class I: No limitation on activity
Class II: Comfortable at rest but symptomatic with ordinary activities
Class III: Comfortable at rest but symptomatic with any activity
Class IV: Symptomatic at rest

69
Q

What is the purpose of measuring NT-proBNP if suspecting heart failure?

A

Indicates how soon an Echo should be done in

70
Q

What is the management for heart failure with reduced ejection fraction?

A

Furosemide
ACEi (Ramipril) can give ARB if not tolerated
Beta-blockers (Bisoprolol)

Give Spironolactone if the above given and still have issues

Cardiac rehab

71
Q

When should an ACEi be avoided with a patient with heart failure?

A

When it’s caused by valvular heart disease

72
Q

What medications can be given to a patient with Heart failure with preserved ejection fraction?

A

Furosemide

Then manage co-morbidities
Cardiac rehab

73
Q

What additional medications can be given in heart failure with reduced ejection fraction (HFrEF)?

A

SGLT2 inhibitor (dapagliflozin)
Entresto (Sacubitril valsartan)
Ivabradine
Digoxin
Hydralazine with nitrate

74
Q

What needs to be regularly monitored in patients being treated for HFrEF?

A

U+Es

75
Q

Why do U+Es need regularly monitoring when managing HFrEF?

A

Loop diuretics , ACEi and aldosterone antagonists cause electrolyte disturbances

ACEi and Aldosterone antagonists can both cause HYPERKALAEMIA

76
Q

What are some procedural or surgical interventions to manage chronic heart failure?

A

Surgery for valvular causes

Implantable cardio defibrillators if theres a shockable arrhythmia

Cardiac re synchronisation therapy

Transplant if serious

Y3(M) - Cardiology (9 decks)

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