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Medicine Clerkship > Learning Objectives - Atrial Fibrillation > Flashcards

Learning Objectives - Atrial Fibrillation Flashcards

1
Q

Risk factors for AF?

A 
Age
HTN
Heart disease
Alcohol use
Family history
Hyperthryoidism
DM
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2
Q

AF on EKG?

A

Irregularly irregular rhythm:

  • Absence of atrial activity (absent P waves)
  • Irregular ventricular pattern (QRS complexes do not occur regularly)

May have rapid ventricular rate (RVR, any rate >100)

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3
Q

When you encounter tachycardia, how should it be further characterized?

A
  1. QRS complexes wide (>120 ms) or narrow (<120)?
    - Wide: usually indicates an electrical problem below the AV node
    - Narrow: source above the ventricles (AF, simple sinus tachycardia)
  2. Regular or irregular rhythm?
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4
Q

What happens in a supraventricular tachycardia?

A

Ventricles are depolarized via the normal His-Purkinje system with or without aberrancy, resulting in a narrow or wide complex tachycardia

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5
Q

List 7 types of supraventricular tachycardia.

A
  1. Atrial tachycardia
  2. Multifocal atrial tachycardia
  3. Atrial flutter
  4. Atrial fibrillation
    5 AV nodal reentrant tachycardia
  5. Pre-exited tachycardia
  6. Accelerated junctional tachycardia
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6
Q

Cause of atrial tachycardia?

A

Ectopic atrial focus discharging faster than sinus rhythm

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7
Q

Rate and P-wave morphology of atrial tachycardia?

A

Usually 100-250 bpm

P-wave usually different than sinus P wave

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8
Q

Rate and P-wave morphology of multifocal atrial tachycardia?

A

Irregular rhythm
Rate >100
Presence of 3+ P-wave morphologies

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9
Q

Rate and P-wave morphology of atrial flutter?

A

Atrial rate: 250-350
Ventricular rate: depends on conduction down the AV node - usually 2:1 (150 bpm)
Saw-tooth P waves

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10
Q

Most common type of SV tachycardia?

A

AV nodal re-entrant tachycardia

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11
Q

What happens in AV nodal re-entrant tachycardia?

A

Sudden onset and termination of a regular narrow QRS complex tachycardia at rates of 150-250 bpm

Wide QRS can occur if aberrant conduction in His-Purkinje

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12
Q

What happens in pre-exicted tachycardia?

A

Some or all of ventricular activation is caused by antegrade conduction down an accessory pathway (WPW, etc.)

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13
Q

What happens in accelerated junctional tachycardia?

A

Rapid irregular SV tachycardia with episodes of AV dissociation

Rate 110-250 bpm
QRS interval usually narrow but may be wide if BBB

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14
Q

Definition of ventricular tachycardia?

A

3+ consecutive ventricular depolarizations at a rate of >100 bpm, wide QRS complex

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15
Q

Define paroxysmal AF

A

Recurrent episodes that self-terminate in <7 days

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16
Q

Define persistent AF

A

Recurrent episodes lasting >7 days

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17
Q

Etiologies of AF?

A

CV disease (HTN, CAD, cardiomyopathy, valvular disease (usually mitral), cardiac surgery, myo/pericarditis)

Excessive alcohol intake
Hyperthyroidism
Pulmonary disorders including PE
Medications (theopylline, caffeine)
Sleep apnea
Lung disease
Systemic illness
Pheochromocytoma
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18
Q

Define chronic/persistent AF

A

Failure to restore normal HR with treatment for >1 year

19
Q

What are the hemodynamic consequences of new onset AF?

A

Irregularity of the cardiac cycle, especially with RVR, leads to reduced diastolic filling, SV, and CO. This is worsened in the setting of mitral stenosis. Syncope can ensue due to lack of cerebral blood flow. Also dyspnea, pulmonary edema, activation of neurohormonal vasoconstrictors, increased mitral regurgitation

20
Q

Three main goals of AF treatment?

A

Anticoagulation
Rate control
Rhythm control

21
Q

In a patient with AF who is hemodynamically unstable, what should be done?

A

Immediate electrical cardioversion

22
Q

In a patient with AF who is hemodynamically stable, what are the cornerstones of treatment?

A

Rate control and anticoagulation

23
Q

Why is rate control important in AF?

A

Chronically elevated HR of 130+ may result in tachycardia-induced cardiomyopathy (LV dysfunction that can be reversed with control

24
Q

Options for rate control?

A

Beta-blockers (metoprolol, esmolol, atenolol)
Non-dihydropyridine CCBs (verapamil, diltiazem) - avoid in CHF or in combo with BB
Digoxin (insufficient during exercise, need to add BB or CCB)

25
Q

Goal HR in AF during rest and exercise?

A

60-80 at rest

90-115 during exercise

26
Q

Significant risk for thromboembolization when AF is present for how long?

A

> 48 hours

27
Q

Rules for anticoagulation vis a vis cardioversion?

A

Anticoagulate for 3-4 weeks before and after cardioversion OR TEE to rule out LA clot

28
Q

Goal anticoagulation range in AF?

A

2.0-3.0

29
Q

Who gets anticoagulated in AF?

A

CHADS2VASC

0 - low risk , +/- aspirin
1 - moderate risk, aspirin or new anti-coagulant
2 - high risk, warfarin or new anticoagulant

Any patient with valvular heart disease - warfarin

30
Q

CHADS2VASC?

A 
CHF (or LV dysfunction)
HTN (>140/90 or medications)
A2 (75+)
DM 
S2 Prior stroke or TIA or thromboembolism
Vascular disease
Age (65-74)
Sex (female) - only added if patient ahs at least 1 other risk factor
31
Q

Options for rhythm control?

A

Class 1 (Na+ chanel blockers)
A - quinidine, procainamide, disopyramide
C - flecainide

Class 3 - amiodarone, sotalol, dofetilide

32
Q

Which rhythm control med is most effective?

A

Amiodarone (but many side effects)

33
Q

Who should be rhythm controlled in AF?

A

Patients who are symptomatic despite rate control

Patients with LV dysfunction

34
Q

When there are no risk factors and the patient is <60 y/o, what is the risk fo stroke in a patient with AF?

A

1.3% over 15 years

35
Q

Who has a 17-18x increased risk of stroke in the setting of AF?

A

Prosthetic heart valves

Rheumatic valvular disease

36
Q

Incidence of stroke with chronic and paroxysmal AF?

A

10-15% in first year after onset

5% risk per year after that

37
Q

Aspirin results in a ___% stroke risk reduction over placebo. Warfarin results in a ___% stroke risk reduction.

A

20-25; 60-70

38
Q

Cons of Class 1A antiarrhythmics (quinidine, procainamide, disopyramide)

A

Increased mortality in post-MI patients
Avoid in all patients with LV dysfunction
Prolong QT

39
Q

Which antiarrhythmics are safe in patients with LV dysfunction?

A

Amiodarone

Dofetilide

40
Q

Drugs of choice for post-op AF following CABG?

A

Beta-blockers

Amiodarone

41
Q

AE amiodarone?

A 
Pulmonary fibrosis
Hepatotoxicity
Hypo/hyperthyroidism
Acts as a hapten -> corneal deposit, blue/gray skin deposits, photodermatitis
Neuro effects
Constipation
Bradycardia, heart block, HF
42
Q

Mechanism of class III?

A

K channel blockers

43
Q

Efficacy of ablation?

A

60-90% effective, less so in chronic AF

44
Q

Efficacy of electrical cardioversion?

A

> 90%, persists beyond 12 months in 30-50%

Medicine Clerkship (15 decks)

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