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RACP Written 2018 > Cardiology - Arrythmias: AF > Flashcards

Cardiology - Arrythmias: AF Flashcards

1
Q

AF Risk Factors:

A

DEMOGRAPHICS

  • western countries
  • males
  • Caucasians

SYSTEMIC

  • Hypertension
  • obesity
  • OSA
  • diabetes
  • hyperthyroidism

STRUCTURAL HEART

  • HOCM
  • Valvular heart disease (esp MS)
  • ACS with HF (NOT IHD itself)

OTHER

  • hypomagnesaemia (50 times more likely)
  • alcohol (esp binge drinking)
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2
Q

Demographic RF for AF

A
  • western countries
  • males
  • Caucasians
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3
Q

Systemic RF for AF

A
  • Hypertension
  • obesity
  • OSA
  • diabetes
  • hyperthyroidism
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4
Q

Structural heart disease RF for AF

A
  • HOCM
  • Valvular heart disease (esp MS)
  • ACS with HF (NOT IHD itself)
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5
Q

Nonspecific RF for AF

A
  • hypomagnesaemia (50 times more likely)

- alcohol (esp binge drinking)

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6
Q

Definition of paroxysmal AF

A

Self terminates within 7 days

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7
Q

Persistent

A

> 7 days

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8
Q

Longstanding persistent

A

> 12 months

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9
Q

Permanent

A

Not for rhythm strategies

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10
Q

AF can develop post cardiac surgery.
How often?
When is greatest risk?
When can you stop anti-arrythmics?

A

Develops in 25%

Greatest risk post op on Day 2 and 3

Usually self-limited
Can stop antiarrythmics by 2-3 months post op

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11
Q

Describe the pathology behind the three phases of AF

A

Phase 1: Paroxysmal AF
- stretch increases propensity for PULMONARY VEIN focuses to develop due to stretch sensitive ion channels

Phase 2: Persistent AF
- over time there is remodelling of left atrium

Phase 3: Permanent AF
- With more time it is more difficult to maintain sinus due to gross electrical and structural atrial remodelling.

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12
Q

What can prevent AF?

A
  • Manage risk factors
  • Mediterranean diet with extra virgin olive oil or mixed nutes
  • Being fit
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13
Q

Once you have an episode of AF what NON-PHARMA measures can prevent RECURRENCE?

A

Weight loss (if >10%) causes SIX TIMES decreased recurrence rate

Increased fitness

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14
Q

When is urgent cardioversion indicated, and when doing it how do you sync the charge?

A

Indicated urgently if HD compromise

Synchronise the R wave to AVOID R-on-T event which provokes VT

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15
Q

? do you need anticoagulation for AF?

A

If AF is definitely <48 hours then you don’t need anticoagulation

BUT

If uncertain duration or >48 hours then:

  • TOE to look for thrombus in LV
  • post chemical cardioversion anticoagulation for 3 weeks
  • post-procedure anticoagulation for 4 weeks
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16
Q

Agents with PROVEN EFFICACY for pharmacologic conversion

A 
Amiodarone
Flecainide
Quinidine
Dofetilide
Ibutilide
Propafenone
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17
Q

Agents which are LESS EFFECTIVE at pharmacological conversion

A 
beta blockers (including sotolol)
CCBs
Digoxin
Disopyramide
Procainamide
18
Q

Why is CHA2DS2-VASc better than CHADS2?

A

It is more SENSITIVE

19
Q

On what score do you anticoagulate on CHA2DS2-VASc

A

If it is >=2

20
Q

Components of CHA2DS2-VASc

A 
Congestive HF (+1)
Hypertension (+1)
Age >=75 (+2)
Diabetes mellitus (+1)
Stroke or TIA (+2)
Vascular disease (+1)
Age 65 - 75yrs (+1)
Sex female (+1)
21
Q

Which components of CHA2DS2-VASc earn 2 points?

A

Age >= 75yrs

Stroke or TIA

22
Q

What are the components of HAS-BLED?

A

+1 point each:

  • Hypertension
  • Abnormal renal Cr>200 or liver (3 x normal)
  • Stroke hx
  • Bleeding hx
  • Labile INR (time in therapeutic range <60%)
  • Elderly >65yrs
  • Drug or alcohol history (>8SD per week) or drugs that cause bleeding
23
Q

What HAS-BLED score is considered HIGH RISK?

24
Q

In anticoagulation of non-valvular AF what NOACs are NONINFERIOR to warfarin AND have lower ICH risk?

A

Dabigatran 110mg BD

Rivaroxaban 20mg daily

25
Q

In anticoagulation of non-valvular AF what NOACs are SUPERIOR to warfarin AND have decreased ICH risk?

A

Apixaban 5mg BD
OR
Apixaban 2.5mg BD if >=2 of age>80, Cr >133 or weight <60kg

26
Q

In using apixaban for stroke prevention in nonvalvuar AF when must the lower dose 2.5mg BD be used?

A

If 2 or more of:

  • age >80yrs
  • Cr >133
  • weight 60kg
27
Q

In anticoagulation of non-valvular AF what NOACs cmopared to warfarin have a MORTALITY benefit?

28
Q

In anticoagulation of non-valvular AF what NOACs have a HIGHER GI BLEED RISK?

A

Dabigatran
Rivaroxaban

(Apixaban has no difference in GI bleed rate!)

29
Q

In AF management should we use rate control or rhythm control in preference?

A

NEITHER!

Rate control is NONINFERIOR to rhythm control for both STROKE and SURVIVAL

30
Q

BUT if we definitely wanted to give RHYTHM control in management of AF who would have a HIGHER mortality with RHYTHM control?

(and therefore should definitely be rate controlled only!)

A

Elderly
Coronary artery disease
CCF

31
Q

In tachycardia-induced cardiomyopathy what should we aim for the HR?

32
Q

If someone has SYMPTOMS would rate or rhythm control be preferred?

A

If symptoms then aim for RHYTHM control

33
Q

Is lenient rate control (aim <110bpm) or strict rate control (aim <80bpm) better?

A

If NOT with underlying cardiomyopathy then there is no significant difference EXCEPT lenient will have less clinic visits

34
Q

If deciding to rate control someone in AF what medications are used first line?

And if they have pre-excitation syndrome what must you avoid?

A

BB and CCBs first line

BUT

If pre-excitation:

  • AVOID CCB and digoxin
  • GIVE beta blockers, flecainide or amiodarone
35
Q

In AF when maintaining sinus rhythm, what are the issues with Class I Sodium Channel Blockers?

A

Class I Sodium Channel Blockers (ie flecainide and propafenon)

  • negative inotrope and pro-arrhythmic effects
  • Don’t use if STRUCTURAL heart disease
  • AVOID in coronary heart disease and CCF
  • Can result in organisation to a flutter with 1:1
36
Q

In AF when maintaining sinus rhythm, what are the issues with Class III Agents?

A

Class III agents such as sotolol, amiodarone and dofetilide

  • able to be used in coronary artery disease and structural heart disease
  • Risk of QTc prolongation and torsades
37
Q

What is the BEST INDICATION to use catheter ablation and pulmonary vein isolation in management of AF?

A

Symptomatic paroxysmal AF refractory or intolerant of AT LEAST 1 Class I or Class III antiarrythmic

38
Q

In catheter ablation of AF when is it best done?

A

Early in AF without significant atrial enlargement

39
Q

If able, why is catheter ablation better than antiarrhytmics in AF?

A
  • better at preventing recurrent atrial tachycardias
  • reduced cardiovascular hospitalisations
  • better QoL
40
Q

Complications with catheter ablation in AF?

A
  • tamponade (1%)
  • Stroke (0.5-1%)
  • Phrenic nerve paralysis
  • Pulmonary vein stenosis (presents years or months later with SOB and haemoptysis)
41
Q

Complications of AF?

A
  • increased all-cause mortality
  • Stroke rate 5% per year (compared to 1% if non-AF)
  • worsened HF
  • Tachycardia associated cardiomyopathy
  • Increased risk dementia
  • increased risk nursing home placement

RACP Written 2018 (167 decks)

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