Cardiology

Question 1

Presentation of AF

Answer 1

Irregularly irregular pulse with pulse deficit (Difference between pulse and HS).
Palpitations
Chest pain
Dyspnoea
Syncope/Dizziness/Fatigue

Question 2

Causes of AF

Answer 2

PIRATES!
Pulmonary (pneumonia, PE and pulmonary disease).
Ischaemia/infarction/idiopathic.
Rheumatic valve disease (MS/MR).
Alcohol/anaemia/age/autonomic tone.
Thyroid disease (Hyperthyroidism).
Elevated BP/Electrolytes/Endocarditis
Sepsis/Sleep apnoea/Surgery

Question 3

AF Investigations

Answer 3

ECG - no discernible or distinct P-wave activity (chaotic baseline) and irregularly iregular ventricular rate.
FBC - to detect non-cardiac factors precipitating AF e.g. anaemia or infection.
U&Es - to exclude renal impairment, hypokalaemia, hyperkalaemia and hypomagnesaemia.
TFTs - to exclude thyrotoxicosis.
Clotting profile - take as a baseline to identify an patient with an underlying coagulation defend and inform management with anticoagulants.
CXR - routine for all cardiac presentations, particularly if suspected lung pathology.
Transthoracic Echo - check patients for LV size and function, LA size, valvular disease and RV size and function.

Question 4

Management of acute AF.

Answer 4

Haemodynamically Unstable
ABCDE and senior input.
DC cardioversion +/- amiodarone (2nd line).
Consider pre-cardioversion anticoagulation but do not delay treatment.
Treat underlying cause.
Longer-term anticoagulation strategy.

Haemodynamically stable: onset<48 hours
Rate control
Early or delayed electrical or pharmacological cardioversion.
Pre-cardioversion anticoagulation.
Treat underlying cause.
Longer-term anticoagulation strategy.

Haemodynamically stable: onset >48 hours/unclear
Rate control
Elective electrical or pharmacological cardioversion
Pre-cardioversion anticoagulation.
Treat underlying cause
Longer-term anticoagulation strategy.