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AKT - Lizzie Bain > CVS: Atrial Fibrillation > Flashcards

CVS: Atrial Fibrillation Flashcards

1
Q

What are the risk factors for AF?

A
  • increasing age
  • HTN
  • obesity
  • diabetes
  • valve disease
  • IHD
  • Heart failure
  • sleep apnoea
  • alcohol
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2
Q

Who should AF be suspected in?

A

People with an irregular pulse +/- any of:
* SOB
* Palpitations
* chest pain
* syncope/presyncope
* Reduced ET, fatigue, polyuria
* TIA/stroke/HF

Suspect paroxysmal AF if symptoms episodic and last <48hrs

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3
Q

What are the ECG features of Atrial Flutter?

A
  • differential for AFib
  • ‘saw tooth’ baseline - most recognisable in II,III, aVF
  • regular atrial activity at rate around 300bpm, transmitted to the ventricles at a fixed rate - causing HR of 75, 100, or 150 depending on A:V conduction ratio
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4
Q

Which investigations should be done in suspected AF?

A
  • ECG
  • FBC, U&E, TFT, BNP if signs of HF
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5
Q

What are the ECG features of AF?

A
  • no p waves
  • chaotic baseline
  • irregular ventricular rate
  • ventricular rate is often 160–180 bpm (can be lower esp. if asymptomatic)
  • ventricular complexes look normal unless there is a ventricular conduction defect.
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6
Q

If ECG is normal in suspected AF what should be done?

A
  • 24hr ECG - if suspected asymptomatic episodes (e.g incidental finding or irregular pulse), or symptomatic episodes <24hrs apart
  • if symptomatic >24hrs apart - 5 day event recorder or 7 day holder monitor
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7
Q

Which patients with confirmed AF should have an ECHO?

A
  • when considering electrical or pharmacological cardioversion
  • suspected underlying HF or valve disease
  • to help stroke risk stratification
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8
Q

What score is used to estimate stroke risk? What score means anticoagulation should be offered?

A
  • CHA2DS2-VASc score
  • anticoagulation should be offered to everyone with score of >=2
  • anticoagulation should be considered in men with score of 1
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9
Q

Which score does NICE recommend to predict bleeding risk?
What score indicates, low, medium and high risk of bleeding?

A
  • ORBIT score
  • <=2 is low risk, 3 is medium risk, >=4 is high risk
  • Should be used to identify reversible factors to lower the bleeding risk
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10
Q

What are the key indications for using warfarin for stroke prevention?

A
  • significant renal impairment CrCl <30 (if CrCl 15-29 can have 2.5mg BD apixaban)
  • mechanical heart valve
  • Hx rheumatic heart disease
  • extremes of body weight >120kg, <50kg
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11
Q

If onset of AF was within the last 48hrs, what are the treatment options?

A
  • urgent admission if haemodynamic instability (rapid HR, Low BP, dizziness, chest pain, SOB)
  • if no haemodynamic instability - refer for electrical/chemical cardioversion OR start rate control.
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12
Q

Rate control is the default treatment except for:

A
  • new onset AF <48hrs -refer for electrical/chemical cardioversion
  • reversible cause for AF (e.g chest infection) -refer for electrical/chemical cardioversion
  • symptomatic flutter - amenable to ablation
  • heart failure due to AF - refer for electrical/chemical cardioversion
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13
Q

What is first line rate control treatment for AF?

A
  • b-blocker (other than sotalol) OR rate-limiting CCB
  • digoxin is an alternative for non-paroxysmal AF if they are sedentary, or if the B-blocker and CCB are contraindicated.
  • F/U <1 week to review symptoms, HR, BP
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14
Q

When should rhythm control be considered?

A
  • symptomatic AF despite rate control
  • will be started in secondary care
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15
Q

Who does ‘pill in pocket’ rhythm control suit?

A

infrequent paroxysmal AF without underlying structural or functional heart disease, without low BP or bradycardia.
e.g. flecainide, sotalol

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16
Q

What is cardioversion and who is it helpful for?

A
  • longer term rhythm control
  • achieved electrically or pharmacologically
  • helpful if: persistent symptoms, acute onset AF, co-morbid disease where it is unclear whether symptoms are due to AF or another cause (e.g. SOB)
17
Q

What are underlying causes of AF?

A
  • cardiac: HTN, valve disease, HF, IHD. Need ECHO if suspecting valve disease or HF (refer cardio). WPW (refer cardio)
  • Resp: chest infection, lung cancer (refer resp oncologist). Need CXR if suspected.
  • systemic: excess alcohol, hyperthyroidism (refer endo), U&E depletion, infection, diabetes - consider need for bloods.

If cause detected - refer as needed / manage as able.

18
Q

What is the first line anticoagulation?

A
  • DOAC (apixaban, dabigatran, edoxaban, rivaroxaban)

Warfarin 2nd line - if DOAC contraindicated, not tolerated

19
Q

When is cardiology referral indicated (also on other cards)?

A
  • suspected AF but not caught on ECG - for ambulatory monitoring
  • confirmed or suspected HF, or valve disease
  • paroxysmal AF, not responding to rate control (ablation or rhythm control may be needed)
  • remain symptomatic despite adequate rate/ rhythm control - cardioversion may be needed
  • high stroke risk not able to take anticoagulation - left atrial appendage occlusion device may be needed
20
Q

What are the Group 1 and Group 2 DVLA rules for driving with AF?

A
  1. stop driving if arrhythmia has caused or likely to cause incapacity. Can drive again when underlying cause identified and controlled for >=4 weeks. No need to notify DVLA unless distracting or disabling symptoms
  2. disqualified from driving if arrhythmia has caused or likely to cause incapacity. May resume when arrhythmia controlled for >=3months, LVEF >=40%, no other disqualifying condition.
21
Q

If a persons symptoms/HR not controlled on 1st line rate control, what should be done?

A
  • increase dose
  • if on max dose - combination treatment: Bblocker and digoxin
  • if not controlled on combo treatment - refer <4weeks to cardio
22
Q

What is the target INR for warfarin in AF?

A

2-3

23
Q

How often should INR be monitored when initiating warfarin?

A
  • daily until in therapeutic range on 2 consecutive occasions
  • then twice weekly for 2 weeks
  • then weekly until two readings are in range
24
Q

How often should stroke risk be reassessed?

A
  • at least annually
  • reassess when reach 65 years of age
  • if they develop new comorbidities
  • DO NOT stop anticoagulation just because AF no longer detectable
  • explain risk of stroke is 5x higher in person with AF
  • anticoagulation reduced risk of stroke by 2/3rds so for most people benefit of anticoagulation outweighs risk.
25
Q

What is the bleeding risk of DOAC compared to warfarin?

A

DOACs have reduced risk of haemorrhagic stroke, and ICH compared to warfarin

There is no antidote for edoxaban

26
Q

Apixaban for stroke prevention is usually 5mg BD, what are the indications for low dose (2.5mg BD)?

A

People with at least 2 of:
* age>=80
* 60kg or less
* Creatinine 133 or above

Or if CrCl is 15-29 ml/min

27
Q

How should DOACs be monitored?

A
  • baseline clotting, U&E, FBC
  • review after 1 month, then every 3 months - can increase up to 6monthly
  • at these reviews - assess:
  • adherence
  • signs of bleeding
  • repeat FBC and U&E yearly (or every 6 months if frail/>75years)
  • If CrCl <60, frequency of monitoring is the CrlCl divided by 10 (in months) e.g 3 monthly for CrCl of 30

AKT - Lizzie Bain (55 decks)

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