Cardiovascular System Flashcards
What is a complication of AF?
Stroke
What are the two types of ‘control’ we can target AF management with?
Rate control or rhythm control
How would you react to an acute presentation of AF if New-onset, life threatening AF?
New-onset, life threatening AF should undergo emergency electrical cardio version without delaying achieve anti-coagulation
How would you react to an acute presentation of AF but NOT new-onset, life threatening AF?
Offer rate or rhythm control if less than 48 hours.
If more than 48 hours, rate control is preferred.
Give examples of pharmacological cardio version drugs:
- IV amiodarone
or
flecainide
(amiodarone is preferred if there is structural disease)
What can you give if urgent rate control is required?
IV beta blocker or verapamil
What is the purpose of a cardio version?
To restore sinus rhythm - it can be either electrical or pharmacological
In a patient presenting with AF for over 48 hours, what type of cardio version is preferred?
Electrical cardioversion - not to be attempted until patient has been fully anti coagulated for at least 3 weeks
If this is not possible, a left atrial thrombus should be ruled out and parenteral anticoagulation (heparin) commenced immediately before cardioversion; oral anticoagulation should be given after cardioversion and continued for at least 4 weeks
What medication is used to control ventricular rate?
Standard beta blocker (not sotalol) or a rate limiting calcium channel blocker such as diltiazem or verapamil
When is digoxin effective in rate control?
Controlling ventricular rate at REST and should only be used as monotherapy in predominantly sedentary patients with non paroxysmal AF
Rate control is first line for AF, when would you consider adding in rhythm control?
If the dual combination of either a beta blocker, digoxin or diltiazem doesn’t control ventricular rate, you would then consider a rhythm control strategy
Is digoxin used when AF is accompanied by congestive heart failure?
Yes
What drug treatment is required to maintain sinus rhythm (‘rhythm control’) post-cardioversion?
consider a standard beta-blocker (not sotalol hydrochloride) as first-line treatment.
If a beta blocker is not appropriate or is ineffective in maintaining sinus rhythm (‘rhythm control’) post-cardioversion, what would you consider?
an alternative anti-arrhythmic drug such as;
- amiodarone hydrochloride, - flecainide acetate,
- propafenone hydrochloride,
or sotalol hydrochloride)
In what patients would you avoid flecainide and propafenone?
In patients with known ischaemic or structural heart disease and, for patients with left ventricular impairment or heart failure
When would you consider dronedarone for AF?
ay be considered as a second-line treatment option in patients with persistent or paroxysmal atrial fibrillation
What is the “pill in the pocket” approach and who is it for?
Selected patients with infrequent episodes of symptomatic paroxysmal atrial fibrillation, sinus rhythm.
It involves the patient taking an oral anti-arrhythmic drug to self-treat an episode of atrial fibrillation when it occurs.
What should all patients with atrial fibrillation (including those with continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm or catheter ablation) should be assessed for?
Their risk of stroke and the need for thromboprophylaxis; this needs to be balanced with the patient’s risk of bleeding
How do we assess stroke risk?
The CHA2DS2-VASc risk tool and bleeding risk using the ORBIT bleeding risk tool
What are the risk factors for stroke taken into account by CHA2DS2-VASc?
age, sex, and prior history of congestive heart failure, hypertension, stroke, transient ischaemic attacks (TIA), thromboembolic events, vascular disease, or diabetes mellitus
Based on the CHA2DS2-VASc, when would anti-coagulation be offered?
all patients with a CHA2DS2-VASc score of 2 or above, and be considered in men with a CHA2DS2-VASc score of 1; these scores should be reviewed at least annually
When would you give parenteral anti-coagulation to patients with new onset AF?
Those who are receiving subtherapeutic or no anticoagulation therapy, until assessment is made and appropriate anticoagulation is started
When would you offer oral anticoagulation to a patient with AF?
To patients with a confirmed diagnosis of atrial fibrillation in whom a stable sinus rhythm has not been successfully restored within 48 hours of onset; or where their risk of stroke outweighs their risk of bleeding; or who have had, or are at high risk of, recurrence of atrial fibrillation such as those with structural heart disease, a prolonged history of atrial fibrillation (more than 12 months), or a history of failed attempts at cardioversion.
Would you give a DOAC to someone with valvular AF?
Oral anticoagulation with a direct-acting oral anticoagulant such as apixaban, dabigatran etexilate, edoxaban, or rivaroxaban, is recommended in non-valvular atrial fibrillation.
If direct-acting oral anticoagulants are contra-indicated or unsuitable, offer a vitamin K antagonist such as warfarin sodium.
Is aspirin monotherapy used solely for stroke prevention?
No - this is not recommended