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S2B6: MEDI > Atrial Fibrillation Treatment & Complications > Flashcards

Atrial Fibrillation Treatment & Complications Flashcards

1
Q

What is Atrial Fibrillation?

A

A supraventricular tachyarrhythmia wth uncoordinated atrial activation and consequently ineffective atrial contraction

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2
Q

What characteristics can be observed on an ECG during atrial fibrillation?

A
  1. Irregular R-R interval
  2. Absence of distinct repeating P waves
  3. Irregular atrial Activity

** if very fast, (greater than 200 bpm) the R-R will already be very fast so it may be difficult to see that it is irregular, so you may have to slow down the pulse before you can diagnose it

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3
Q

What is the cause of the irregular rhythm seen in atrial fibrillation?

A

Everything in the atria is in a circus rhythm, which is where the irregularity comes in & when you have a depolarization touch the AV node, it sends it to the ventricle, causing the irregularity of ventricular contraction

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4
Q

What are the major steps to atrial fibrillation diagnosis?

A
  • Pulse palpation (can help you identify irregularity)
  • 12 lead ECG
  • Holter monitoring
  • Others
    • Echocariogram (can see that they are not having normal atrial contractions)
    • Labs
      • Thyroid function test (TFT), electorlytes, clotting, Liver function test (LFT), CBC
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5
Q

How could you identify this ECG as atrial fibrillation?

A
  • Rate
    • not identifiable because they are variable (R-R)
    • irregular
  • P waves?
    • no distinct P waves
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6
Q

What is the criteria for an ECG diagnosis of atrial fibrillation?

A
  • P waves are absent adn R-R interval is variabl
  • f-waves (atrial rate - 350-600 beats/min)
  • Ventricular response in grossly irregular at 100-160 beats/min
  • Rate: no. of R waves x 6 (10 sec strip)
    • also, notice the R waves may have different amplitudes reflecting the different amount of time for preload & repolarization
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7
Q

What percent of individuals aged 40 and older will develop atrial fibrillation?

A

25%

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8
Q

Is the prevalence of atrial fibrilation higher in males or females?

A

males

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9
Q

How does the addition of atrial fibrillation affect the occurrence of the following situations

Death

Stroke

Hospitalization

Quality of life & Exercise capacity

LV function

A
  1. Death rate is doubled
  2. Stroke risk increases 5x
  3. Hospitalization is more frequent
  4. Quality of life & Exercise capacity can be markedly decreased
  5. LV function - tachycardia myopathy / heart failure
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10
Q

Fill out the indicated spaces in the provided table

Far right column is preferred treatment

A
  • have to document the initial event (when they first felt palpitations)
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11
Q

What are the cardiac etiologies of atrial fibrillation?

A
  • hypertensive heart disease
  • valvular heart disease
  • ischaemic heart disease
  • cardiomyopathy
  • pericarditis
  • congenital heart disease
  • post cardiac surgery
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12
Q

What are the non-cardiac etiologies of atrial fibrillation?

A
  1. Pulmonary: pneumonia, COPD, PE
  2. hyperthyroidism
  3. excess catecholamine / sympathetic activity
  4. drugs and alcohol (meth)
  5. significant electrolyte imbalance (K+, Ca2+)
  6. thyrotoxicosis
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13
Q

What are the characteristics of long atrial fibrillation?

A
  • Purely an electrical diagnosis
    • younger patients <60
    • no underlying cause
    • usually not much symptoms
    • normal heart structure
    • no associated co-morbidities
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14
Q

What is the pneumonic for precipitants of atrial fibrillation?

A
  • P: pulmonary embolism
  • I: ischemia (cardiac)
  • R: respiratory disease
  • A: atrial enlargement or myxoma
  • T: thyroid disease (check 1st episode TSH)
  • E: EtOH withrawl (“holiday heart”)
  • S: sleep anea / sepsis

also consider chronic hypertension & myocarditis

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15
Q

Why is atrial fibrillation management important?

A

Extremely common & can lead to symptoms

  • Potentiall serious consequences
    • embolism
    • impaired cardiac output
    • increased mortality
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16
Q

Non-dihydropyridine calcium channel blockers are contraindicated in patients with what conditions?

A

patients with left ventricular systolic dysfunction & decompensatd heart failure b/c of their negative inotropic effects

17
Q

Fill out the treatment diagram based on the indicated conditions

A
18
Q

What time frame indicates acute atrial fibrillation & how is it managed?

A
  • Hemodynamically unstable
    • hypotension/acute heart failure/chest pain (MI)/syncope/Altered mental status
    • use DC cardioversion - ACLS algorithm
      • synchronized shock, b/c they do have a pulse
  • Hemodynamicallly stable
    • rate control: if significant tachycardia
    • rhythm control: flecainide, propafenone (cl-l), amiodarone, sotalol (cl-III)
    • anticoagulant: LMWH, UFH
19
Q

Describe the management of permanent atrial fibrillation

A
  • heart rate control
    • minimize symptoms associated with excessive heart rates
    • prevent tachycardis-associated cardiomyopathy
  • anticoagulation
20
Q

In which scenarios is rhythm control the preferred therapy?

A
  • first epidose
  • reversible cause (alcohol)
  • symptomatic patient despite rate control
  • patient unable to take anticoagulant (falls, bleeding, noncompliance)
  • CHF precipitated or worsened by afib
  • young afib patient (to avoid chronic electrical & anatomic remodeling that occurs with afib)
21
Q

In which scenarios is rate control the preferred therapy?

A
  • age > 65, less symptomatic hypertension
  • recurrent afib
  • previous antiarrhythmic drug failure
  • unlikely to maiintain sinus rhythm (enlarged LA)
22
Q

Why is cardioversion performed & what are the two types?

What other drug needs to be administered during a cardioversion? Why?

A
  • Cardioverstion is performed as part ofa rhythm-control treatment strategy
  • Types
    • electrica (ECV)
    • pharmacological (PCV)
  • Cardioversion of AF is associated with increased risk of stroke in the absence of antithrombotic therapy
23
Q

What are the uniqe risks associated with rhythm control drugs as compared to rate control in the Affirm study?

A
  • 80% needed to hospitalized (opposed to 73% with rate control)
  • chance of survival from entering bradycardia or pulseless electrical activity (PEA) - common with rhythm control - is less than chance of survive after entering vfib or vtach caused by rate conrol drugs
  • higher change of entering torsades de pointes
  • No difference: death, disabling stroke, majore bleed or cardiac arrest
  • Sinus rhytm maintained only 63% of rhythm contorl group
24
Q

What are the major rate control drug options?

A
  • Beta blocker
  • calcium channel blocker
  • digoxin
  • AV junction ablation pluc pacemaker
25
Q

How is stroke risk affected by atrial fibrillation?

include percentages for both below 60 & above 80

A
  • without AF
    • < 60 yrs: 0.5%
    • > 80 yrs: 3%
  • with AF
    • < 60 yrs: 3% (5x higher)
    • > 80 yrs: 30% (10x higher)
26
Q

What are the clinical factors accociated with risk of stroke in patients with atrial fibrillation?

A
  • mitral stenosis
  • previous stroke
  • increasing age
  • hypertension
  • CCF
  • diabetes
  • CHD
  • Hyperthyroidism
27
Q

What are the echo factors accociated with risk of stroke in patients with atrial fibrillation?

A
  • mitral stenosis
  • LV dysfunction
  • Left atrial spontaneous contrast (left atrial enlargment)
28
Q

How do you calculate someone’s CHA2DS2VASc?

** very likely will be on exam

A
29
Q

What is the percent stroke risk associated wtih each level of

CHA2DS2VASc?

A
30
Q

What criteria can lead to increase risk of a major bleed on an anticoagulant on anticoagulation for atrial fibrillation?

What is indicated “high risk”?

A

> 3 = high risk

major bleed: intracranial, HB drop > 2gm, transfusion, hospitilization

31
Q

What is themost common anticoagulant we use with atrial fibrillation?

A

warfarin

32
Q

With atrial fibrillation, what is the target INR?

A

2-3

?? I don’t really know what this means

33
Q

What patients should remain on warfarin?

A
  • patients already receiving warfarin and stable whose INR is easy to control
  • If dabigatran, rivaroxaban, apixaban are not available
  • Cost
  • if patient is not likely to comply with twice daily dosing (Dabigatran, Apixaban)
  • Chronic kidney disease (GFR < 30 ml/min)
34
Q

What is RF ablation therapy?

A

rhythm control strategy

electrophysiology

can ablate around the pulmonary veins, where a lot of afib originates

35
Q

When should you consider ablation therapy?

A

antiarrhythmic therapy ineffective

antiarrhythmic therapy not tolerated

symptomatic afib

36
Q

Ablation should be considered as a first strategy for individuals with what characteristics?

A
  • patients very symptomatic in AF and refuses antiarrhythmic drug therapy
  • young patients whose only effective antiarrhythmic drug is amiodarone
  • patient with significant bradycardia for whome antiarrhythmic drug therapy will require pacemaker

S2B6: MEDI (15 decks)

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