Cardiology: Cardiac Arrhythmia - AF II Flashcards
What is meant by a ‘holiday heart’? [1]
Holiday heart syndrome typically refers to atrial fibrillation induced by binge alcohol consumption, frequently observed during long weekends, vacations, and holidays.
Describe the principles of managment of AF [2]
Rate or rhythm control
Anticoagulation to prevent strokes
TOM TIP: The following details on rate and rhythm control get quite detailed and complex. Most patients will end up on a beta blocker for rate control, often bisoprolol, plus a DOAC for anticoagulation. If you remember one thing about the treatment of atrial fibrillation, remember this combination.
Describe the treatment used for rhythm control for AF [3]
DC Cardioversion
- electrical stimulation to restore sinus rhythm
Amiodarone
- antiarrhythmic drug which can restore sinus rhythm on its own. It is suitable in most patients
Flecainide
- an antiarrhythmic drug that can be used in some patients to restore sinus rhythm, but is contraindicated in those with possible structural or ischaemic heart disease
Describe the medication used for rate control in the treatment of AF [3]
Rate control aims to get the heart rate below 100 and extend the time during diastole for the ventricles to fill with blood.
Beta blocker:
- atenolol or bisoprolol
CCB:
- Diltiazem or verapamil
Digoxin
NICE guidelines (2021) suggest all patients with AF should have rate control as first-line, except in which four instances? [4]
NICE guidelines (2021) suggest all patients with AF should have rate control as first-line, except with:
- A reversible cause for their AF
- New onset atrial fibrillation (within the last 48 hours)
- Heart failure caused by atrial fibrillation
- Symptoms despite being effectively rate controlled
Describe the different types of DC Cardioversion for AF rhythm control [4]
For cardioversion, there is a choice between:
- Immediate cardioversion
- Delayed cardioversion
There are two options for immediate cardioversion:
* Pharmacological cardioversion
* Electrical cardioversion (recommended)
Electrical cardioversion aims to shock the heart back into sinus rhythm. It involves using a cardiac defibrillator machine to deliver controlled shocks. This is usually done with sedation or general anaesthesia.
Immediate cardioversion is used to treat AF in which instances? [2]
- AF present for less than 48 hours
- Causing life-threatening haemodynamic instability
Which drug is usually considered before & after electrical cardioversion to prevent AF from recurring? [1]
Amiodarone may be considered before and after electrical cardioversion to prevent AF from recurring.
Long-term AF rhythm control is with which drugs? [3]
Beta blockers first-line
Dronedarone second-line for maintaining normal rhythm where patients have had successful cardioversion
Amiodarone is useful in patients with heart failure or left ventricular dysfunction
Describe the Management of Paroxysmal Atrial Fibrillation [1]
Which drug is used? [1]
What other medication should still be continued? [1]
“pill-in-the-pocket” approach.:
- they take a pill to terminate their atrial fibrillation only when they feel the symptoms starting.
Flecainide is the usual treatment for a pill-in-the-pocket approach.
Patients with paroxysmal atrial fibrillation should still be anticoagulated based on their CHA2DS2-VASc score, similar to permanent atrial fibrillation.
What are the options of AF treatment when rate or rhythm control is not tolerated / adequate?
Ablation:
- Left atrial ablation
- Atrioventricular node ablation and a permanent pacemaker
Describe the process of left atrial ablation [8]
Left atrial ablation is performed in a catheter laboratory, often called a “cath lab”.
Under general anaesthetic or sedation
A catheter is inserted into a femoral vein and fed through the venous system under x-ray guidance to the heart
The catheter punctures through the septum into the left atrium.
Once in the left atrium, it is placed against different areas to test the electrical signals.
The operator attempts to identify the location of any abnormal electrical pathways.
Once identified, radiofrequency ablation (heat) is applied to burn the abnormal area of electrical activity.
This leaves scar tissue that does not conduct electrical activity
Describe the process of AVN ablation to treat AF [3]
Atrioventricular node ablation involves destroying the connection between the atria and ventricles (the atrioventricular node)
After the procedure, the irregular electrical activity in the atria cannot pass through to the ventricles
A permanent pacemaker is required to control ventricular contraction
Anticoagulation is still needed to prevent strokes.
What are the anticoagulants that NICE guidelines (2021) recommend for AF? [2] :
Direct-acting oral anticoagulants (DOACs) first-line:
- Apixaban
- edoxaban
- rivaroxaban
- dabigatran
Warfarin second-line, if DOACs are contraindicated
Why are DOACs 1st line c.f. to warfarin with AF? [1]
Direct-acting oral anticoagulants (DOACs) are oral anticoagulants that do not require INR monitoring, unlike warfarin
Explain the treatment that can be used as an option for those with contraindications to anticoagulation and a high stroke risk [1]
Left atrial appendage occlusion:
- The left atrial appendage is a small pouch in the wall of the left atrium. It is the most common site for a thrombus to form.
- Left atrial appendage occlusion involves inserting a catheter into the femoral vein, feeding that through the venous system to the right atrium and puncturing the septum between the atria to access the left atrium. Then, a plug is placed in the left atrial appendage, preventing blood from entering that area.
