Atrial Fibrillation Management

Question 1

What is AF?

Answer 1

Atrial fibrillation (AF) is a supraventricular tachyarrhythmia resulting from irregular, disorganized electrical activity and ineffective contraction of the atria. The disorganised electrical impulses in that atria that causes them to fibrillate is usually at a rate of 300-600 bpm.

Question 2

What are the three classifications for AF according to patterns of episodes?

Answer 2

Question 3

What are other cardiac causes of AF?

Answer 3

Question 4

What are the symptoms for suspected AF in people with an irregular pulse with or without any of the following?

Answer 4

Question 5

When should paroxysmal AF symptoms be suspected?
a. Less than 24 hours
b. Less than 48 hours
c. Less than 72 hours
Greater than 43 days

Answer 5

a. Suspect paroxysmal AF if symptoms are episodic and last less than 48 hours.

Question 6

What test must be conducted to confirm diagnosis of AF?

Answer 6

12-lead ECG
Echocardiogram: because AF can occur secondary to AF.
Blood test- FBC; U&Es, BNP: To rule out underlying HF
Thyroid function test-to rule out secondary causes.
Chest X-ray: Rule out infections

Question 7

What critieria must be met for the diagnosis of AF to be made?

Answer 7

Standard 12-lead ECG recording or a single-lead ECG recording of ≥30 seconds showing a heart rhythm of no discernible repeating P-waves AND
Irregular RR intervals

Question 8

What are the differentials of an irregular pulse and how do they present?

Answer 8

• Atrial flutter (tricuspid involvement) — characterized by a saw-tooth pattern of regular atrial activation on the electrocardiogram.
  
  • Atrial extrasystoles — common and may cause an irregular pulse.
  • Ventricular ectopic beats.
  • Sinus tachycardia — sinus rhythm with more than 100 beats per minute.
  • Supraventricular tachycardias, including atrial tachycardia, atrioventricular nodal re-entry tachycardia, and Wolff-Parkinson-White syndrome (rhthym control issue, more info go on Ninja Nerd).
  • Multifocal atrial tachycardia — often seen in people with severe pulmonary disease.
    Sinus rhythm with premature atrial or ventricular contractions.

Question 9

What test should be order in primary care setting for Ptx with palpitation that are non-life threatening? Why would you order these tests?

Answer 9

Question 10

What is the two driving group entitlements that result in banning from driving if arrthymia hasn’t been controlled in X amount month/time?

Answer 10

Question 11

If Ptx presents with rapid pulse (>150 bpm) and or low BP (<90 mmHg) where would you refer them to and why?

Answer 11

Urgent care because they are hemodynamically unstable.

Question 12

If Ptx is presenting in secondary care with suspected AF what are the test you will perform to rule out secondary causes and why?

Answer 12

Question 13

When is anticoagulant indicated in men and women WITH AF using X scoring system?

Answer 13

Offer anticoagulation with a direct-acting oral anticoagulant (DOAC) to people with AF and a CHA2DS2VASc score of 2 or above. For MEN with AF consider DOAC if CHA2DS2Vasc is: 1.

Question 14

What does the CHA2DS2VASc stand for and what are the scoring bands?

Answer 14

Question 15

What tool is used to measure bleeding risk to help guide decisions on anticoagulation?

Answer 15

Males with haemoglobin <130 g/L or hematocrit <40%.
Females with haemoglobin <120 g/L or hematocrit <36%.
People with a history of bleeding (for example, gastrointestinal or intracranial bleeding, or haemorrhagic stroke).

Question 16

What scores 1 point when using the ORBIT score?

Answer 16

Aged over 74 years.
Who have an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m2.
Treated with anti-platelets.

Question 17

• What are is the range for patient with High ORBIT bleeding score risk?
  A. 2.5-3.5
  B. 4-6
  C. 5-8
  D. 4-7

Answer 17

D

Question 18

• What are the ranges used to stratify high,medium and low bleeding risk?

Answer 18

Question 19

• In Ptx presenting with life threatening hemodynamic instability caused by new-onset AF you would rate control? True or False

Answer 19

False: Carry out emergency electrical cardioversion, without delaying to achieve anticoagulation, in people with life‑threatening haemodynamic instability caused by new‑onset atrial fibrillation.

Question 20

In Ptx presenting with AF acutely w/o hemodynamic instability what should be offered in the first 48 hours?

Answer 20

○ Offer either rate or rhythm control if the onset of the arrhythmia is less than 48 hours.
○ Rate control is preferred.
Rhythm control if there is no sinus rhythm

Question 21

First line agent if URGENT rate control is required?

Answer 21

Beta blocker intravenously; a rate-limiting CCB such as verapamil ( if LVEF>40%)

Question 22

• First line for atrial fibrillation presenting in the first 48 hours, with non-sinus rhythm?

Answer 22

Electrical cardioversion