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3.23 > Lecture 25: Stroke and Atrial Fibrillation > Flashcards

Lecture 25: Stroke and Atrial Fibrillation Flashcards

1
Q

What is atrial fibrillation?

A

Supraventricular tachycardia characterised by disorganised atrial electrical activity, resulting in absence of significant atrial depolarisation

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2
Q

What is the ventricular rate during atrial fibrillation?

A

Rapid and irregular

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3
Q

What is the ECG like during atrial fibrillation?

A

No P waves

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4
Q

What are the symptoms of atrial fibrillation?

A
  • Feeling breathless or having difficulty beathing
  • Dizziness, lightheaded or feeling faint
  • Feeling your heart racing (palpitations)
  • Tiredness or weakness
  • Chest discomfort
  • Difficluty exercising
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5
Q

How is atrial fibrillation diagnosed?

A
  • ECG
  • Holter monitor
  • Loop recorder
  • Echo: doesnt diagnose, just shows damage to heart muscle
  • Blood results: doesnt diagnose - helps rule out underlying conditions - diabates, hyperthyroidism, anaemia, renal function, high cholesterol
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6
Q

Why does atrial fibrillation need to be managed?

A
  • To reduce the risk of developing embolic stroke – anticoagulants
  • Reduce the risk of developing heart failure/ LVSD
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7
Q

What is the CHADSVAS score?

A
  • Chronic heart failure
  • Hypertension
  • Age
  • Diabetes
  • Stroke/ TIA
  • Vascular diseases (IHD, PAD)
  • Sex (female at a higher risk)
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8
Q

What are the treatment options for atrial fibrillation?

A
  • Warfarin
  • Direct oral anticoagulant: Apixaban or Edoxaban
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9
Q

What is the standard dose of apixaban?

A

5mg BD

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10
Q

When do you reduce the dose of apixaban?

A

If 2 of these are met:
- Age >80
- Weight <60kg
- Creatinine >133micrmol/ l
Reduce to 2.5 mg BD

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11
Q

What is the standard dose of edoxaban?

A

60mg OD

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12
Q

When do you reduce the dose of edoxaban?

A

Reduce to 30mg OD if CrCl 15-50ml/ min

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13
Q

What is rate control?

A

Slowing the heart rate

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14
Q

What is rhythm control?

A

get back into sinus rhythm

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15
Q

How can symptoms of atrial fibrillation be resolved?

A

Controlling the ventricular rate in patients with atrial fibrillation can resolve symptoms by using AV blocking drugs

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16
Q

What are the AV blocking drugs?

A
  • beta-blockers
  • non-dihydropyridine calcium channel blockers (verapamil)
  • digoxin
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17
Q

What is first line treatement for rate control?

A

Beta blockers (atenolol)

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18
Q

How do beta blockers alleviate symptoms of atrial fibrillation?

A

Antagonise beta-receptors, resulting in decreased conduction through the AV node, which reduces the heart rate in patients with atrial fibrillation.

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19
Q

How do calcium channel blockers alleviate symptoms of atrial fibrillation?

A
  • reduce AV conduction by antagonising voltage gated calcium channels, decreasing intracellular calcium.
  • reduce left ventricular contractility via the same mechanism, and therefore contraindicated in patients with left ventricular systolic dysfunction (LVSD).
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19
Q

How do calcium channel blockers alleviate symptoms of atrial fibrillation?

A
  • reduce AV conduction by antagonising voltage gated calcium channels, decreasing intracellular calcium.
  • reduce left ventricular contractility via the same mechanism, and therefore contraindicated in patients with left ventricular systolic dysfunction (LVSD).
20
Q

What is a rate contorlling drug?

A

Digoxin

21
Q

What is 1st line treatment in patients with acute heart failure symptoms and AF?

A

Digoxin

22
Q

How does digoxin work?

A

blocks the sodium/potassium ATPase pump.

23
Q

How should digoxin be prescribed?

A

Recommended to use digoxin in combination with a beta-blocker or non-dihydropyridine calcium channel blocker because its effective to reduce ventricular rates at rest but not effective during physical activity.

24
Q

What are the rhythm controlling drugs?

A
  • amiodarone
  • flecainide
25
Q

What class of drug is amiodarone?

A

Class III

26
Q

What class of drug is flecainide?

A

Class IC

27
Q

How does amiodarone work?

A

Blocks potassium channels

28
Q

What is the half life of amiodarone?

A

42 days

29
Q

How does flecainide work?

A

maintain sinus rhythm or chemical cardioversion

30
Q

What is a contraindication of flecainide?

A

Significant coronary artery disease

31
Q

What is pill in the pocket?

A

Someone prone to symptoms of AF but doesn’t want to be on long term medication so they keep 2 tablets of flecanide and take whenever they have symptoms

32
Q

When should Direct Current CardioVersion (DCCV) be done?

A

If patient:
- haemodynamic unstable
- Has SBP < 90 mmHg
- Has Chest pain / heart failure symptoms
- Reduced conscious level
- Known onset of AF (<48 hours)

33
Q

What is a stroke?

A

Stroke is a clinical syndrome characterised by sudden onset of rapidly developing focal or global neurological disturbance which lasts more than 24 hours or leads to death.

34
Q

What is a transient ischaemic attack?

A

transient (less than 24 hours) neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without evidence of acute infarction

35
Q

What is a thrombotic stroke?

A

Blood clot (thrombus) blocks flow of blood in the brain

36
Q

What is an embolic stroke?

A

Fattty plaque or blood clot (embolism) breaks away and flows to the brain where it blocks an artery

37
Q

What is cerebral hemorrhage?

A

Break in blood vessel in the brain

38
Q

What is a lacunar stroke?

A

Small vessels deep in the brain affected

39
Q

What is a thrombotic stroke in large vessels?

A

hyperlipidemia with unstable plaque

40
Q

What is Cardiogenic (Embolic) stroke

A

Clot moves from the heart and lodges in a vessel in the brain

41
Q

What are the initial potential complications of strokes?

A
  • Haemorrhagic transformation of ischaemic stroke
  • Cerebral oedema.
  • Seizures.
  • Venous thromboembolism
  • Cardiac complications
  • Infections
42
Q

What are the Long-term potential complications associated with a stroke?

A
  • Mobility problems: Hemiparesis or hemiplegia (weakness on one side of the body), Ataxia (lack of co-ordination of movement), Falls,
    Spasticity and contractures. Spasticity is common following stroke and can lead to discomfort, pain, difficulties for carers and restriction of activities.
  • Sensory problems
  • Continence problems
  • Pain
  • Dysphagia (difficluty swallowing)
  • Visual problems
43
Q

What is acute stroke care?

A
  1. Admit to stroke unit
  2. Imaging - CT scan
  3. Swallow
  4. Assess medicines - STOP all anticoagulants, thrombolytics, antiplatelets and NSAIDs pending CT result
44
Q

What are the complications of a thrombolysis?

A
  • Intra –cerebral haemorrhage
  • Angioedema
  • Bleeding-minor bleeding is common (IV site)
  • Anaphylaxis
45
Q

What is secondary prevention for stroke?

A
  • Antiplatelets/Anticoagulants: Aspirin given on day of admission
  • Blood pressure: don’t want to lower BP too much & reduce perfusion to vital organs
  • Cholesterol: Atorvastatin 40 mg – 80 mg is used 1ST line. Statins should NOT be used in patients with haemorrhagic stroke unless risk of vascular event outweighs risk of haemorrhagic event.
  • Diabetes: high incidence of stroke in patients with diabetes
  • Exercise: overwieght increase risk of stroke, smoking increses risk and alcohol
46
Q

When should aspirin be avoided?

A

Avoided for 24 hours post thrombolysis as it would increase the risk of bleeding.

47
Q

What is given to patients in sinus rhythm with a stroke?

A
  • 14 days aspirin 300 mg then clopidogrel 75 mg daily
  • Clopidogrel 75mg (unlicensed in TIAs)

3.23 (26 decks)

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