CCS Atrial Fibrillation 2020 Flashcards
Who has more Afib men or women?
Male (1.5x)
What are 7 triggers for Afib from every day life/substances ?
- stimulants
- ETOH
- Sleep deprivation
- Emotional stress
- Physical exertion
- Sleep
- Digestive
What are the 5 CCSAF scores?
0: No symptoms
1: Minimal symptoms
2: Minor effect/Mild awareness
3: Moderate effect, aware on most days
4: Severe impact
What is recommendation for screening?
‘Opportunistic screening’ > 65 -> meaning trying to detect AF during medical encounters
In patients with AF what is BP ETOH and OSA recommendation?
ETOH 1 or less drink per day
OSA (AHI > 15/hour) -> CPAP
130/80mmhg at rest and <200/100mmhg
Which two patients population to use VKA instead of DOAC?
- Mechanical valve
- Moderate to severe MS
Screening renal function for patients on OAC?
Baseline and then annually
What does CCS recommend for DOAC when CrCl 15-30?
Follow normal algorithm (No RCT data though)
How advanced does Liver disease need to be to not use DOAC?
Severe, CP score C
How to manage OAC around catheter ablation?
Uninterrupted OAC
How to manage OAC after 2 months post ablation if successful?
No change -> as per CCS algorithm
What 4 populations on AF to bridge?
- Mechanical valves
- Moderate-severe MS
- CHADS 5-6
- Recent Stroke/TIA
Approach to peri-op with VKA if no bridge?
Hold 5 days before, measure INR 1 day before. Proceed if INR < 1.5
Approach to peri-op with VKA if bridge planned?
Hold 5 days before, LMWH 3 days before , then LMWH post until therapeutic
When to hold DOACs pre op? (Exclude Dabigatran)
-1 day before if low/moderate bleeding risk, 2 days before if high bleeding risk
When to hold Dabigatran pre op if CrCl < 50?
- Last dose 3 days before if low/mod risk
- Last dose 5 days before if high risk
What is Andexanet Alfa reversal agent for?
- Apixaban
- Edoxaban
- Rivaroxaban
When to start OAC in acute ischemic stroke with New AF based on severity?
- Mild Stroke (NIHSS < 8) : 3 days
- Moderate Stroke (NIHSS 8-15) : 6 days
- Large Stroke (NIHSS > 16) : 12 days
Indications for LAA Occluder?
- Moderate to high risk of stroke
- Absolute CI to OAC
5 patient populations to pursue rhythm control
- Recent diagnosed in 1 year
- highly symptomatic/QOL impairment
- Multiple recurrences
- Difficulty with rate control
- arryhthmia induced CMO
Efficacy of DCCV?
90%
What is DCCV recommended dosing?
150 J biphasic waveform
How long to follow patients after provoked Afib?
Indefinitely: opportunistic screening
9 ways to reduce post op Afib ?
Beta blockers
Amio
Sotalol
Atrial overdrive pacing
Magnesium
Posterior Pericardectomy
Colchicine
Statins
Antioxidants
What to do in young patients with lone AF ?
EPS to rule out SVT
Alternative to Procainamide in WPW AFib?
Ibutilide
What are 8 labs that should be ordered in new Afib?
- CBC
- Lytes + Mg/Ca
- Urea/Cr
- TSH
- Liver panel
- Hba1c
- Fasting Lipid Profile
- INR + PTT
What is weight loss target for patients with Afib?
Lose 10% of body weight to BMI < 27
When to dose reduce Apixaban?
2/3:
Age > 80
Wt < 60kg
Cr > 133
When to dose reduce Dabigatran?
Age > 80
Age > 75 with bleeding risk factors
CrCl 30-50
What is renal dosing for Edoxaban and Rivaroxaban and what is the GFR cut off?
Edoxaban 30mg
Riva 15mg
eGFR 30-50
Do not use if eGFR < 30 (very little RCT data as per CCS AF 2020)
What are the recommendations for length of dual therapy post PCI?
1 to 12 months then continue OAC
What was Rivaroxaban dose in PIONEER AF?
15mg
How to manage VKA/DOAC when emergent procedure warranted? Semi-Urgent?
Emergent:
- VKA: Vitamin K 5-10mg IV, Consider PCC
- DOAC: Consider Antidotes, PCC if no antidotes
Urgent: Delay surgery 12-24h if possible
- VKA: Vitamin K 2.5-5mg IV
- DOAC: Defer 12-24h, Idarucizumab for Dabi
How to manage VKA around procedure if no bridging? If bridging?
No Bridging: Stop VKA 5 days before, Check INR day before (If INR > 1.5 -> Vitamin K) -> Restart Day 1 after
Bridging: Stop VKA 5 days before, LMWH 3 days before, check INR day before -> Restart LMWH day after
How to manage DOAC (Non Dabigatran) around OR depending on High vs Low/Mod bleeding risk?
- Low/Mod: Stop DOAC 2 days prior -> Restart day after
- High: Stop DOAC 3 days before -> Restart 2 days after
How to manage Dabigatran + CrCl < 50 around OR depending on High vs Low/Mod bleeding risk?
- Low/Mod: Stop 3 days before -> restart day after
- High: Stop DOAC 5 days before -> Restart 2 days after
Who should have catheter ablation of Afib?
Symptomatic after an adequate trial of anti arrhythmic therapy in whom a rhythm control strategy is desired
When to Ablate AV node when patients are BiV paced?
when BiV pacing < 95% despite maximal AV blockade
Patients you would want on rhythm control?
- Symptoms not controlled on rate control (strong recommendation)
- New Afib (weak recommendation)
When to refer for Catheter Ablation?
- Catheter Ablation in AF patients who are symptomatic after AAD trial and rhythm control strategy still required (Strong recommendation)
- First line therapy in selected patients (Weak recommendation)
When to anticoagulate for SCAF?
-SCAF > 24 hours for CHADS score > 0
5 populations to avoid Class 1c’s for pill in pocket?
- LVEF < 40%
- Ischemic heart disease (need EST if over age 50)
- Preexcitation
- Severe hepatic or renal dysfunction (eGFR < 35)
- AV block or LBBB or RBBB + LAFB
5 populations to avoid Sotalol in?
- Baseline QTc prolongation
- eGFR < 40 (Daily dose if eGFR 40-60)
- LVEF < 40% (with no ICD)
- Multiple RFs for Long QT
- High grade AV block
How to monitor patient on Sotalol?
ECG at 48-72 hours, DC if Qtc > 500 msec
5 populations that Amiodarone should be avoided in?
- High grade AV block
- Active hepatitis/significant chronic liver disease
- Pulmonary interstitial abnormalities
- Pre-existing QTc prolongation
- Hypersensitivity to iodine
- Concomitant use of strong CYP3A4 inhibitors (Ketocanozole, cyclosporine, Ritonavir, Macrolides)
Name 5 populations that Dronedarone should be avoided?
- Permanent AF
- LVEF < 40% or clinical HF
- Significant conduction system disease
- Severe hepatic disease
- QTc prolongation
- Previous lung or liver injury with Amiodarone
