TP9.1 - Abordagem e tratamento da FA

Question 1

Ritmo sinusal?

Answer 1

• 1 onda P, e só 1, antes de cada QRS

- P positiva em I, II e V6; negativa em aVR

Question 2

Taquiarritmias Supraventriculares?

Answer 2

• Formação do impulso acima da bifurcação do feixe de His (aurículas ou nó AV)

Question 3

Fibrilhação Auricular?

Answer 3

A supraventricular tachyarrhythmia with uncoordinated atrial electrical activation and consequently ineffective atrial contraction.

• Irregularly irregular R-R intervals
• Absence of distinct repeating P waves
• Irregular atrial activations

Question 4

Fatores de Risco de Fibrilhação Auricular?

Answer 4

• Genéticos
• Idade
• Etnicidade
• Male sex

Question 5

Apresentação Clínica de FA?

Answer 5

Assintomática ou Silenciosa

Sintomática - Palpitações, Dispneia, Fadiga, … , Hemodynamically Unstable or Stable

Question 6

FA-related Outcomes?

Answer 6

Death
Stroke
LV Dysfunction / Heart Failure
Cognitive decline / Vascular dementia
Depression
Impaired life quality
Hospitalizations

Question 7

Systems used for AF Screening?

Answer 7

• Pulse palpitation, auscultation
• Smart-watch
• ECG
• Holter
• Cardiac monitors
• Wearable belts
• …

Question 8

Fibrilhação auricular - Resposta ventricular?

Answer 8

• Rápida, irregular, no doente não tratado: 120-160 BPM (até > 200)
• Dependente: do tónus vagal & da condução intrínseca do nó AV → < 100 BPM

Question 9

Recommendations for screening to detect AF?

Answer 9

• • Opportunistic by pulse taking or ECG rhythm strip is recommended in patients >65y of age
• • Interrogate pacemakers and implantable cardioverter defibrillators on a regular basis for AHRE (Atrial high-rate episode)
• • Systematic ECG screening should be considered to detect AF in individuals aged >75y, or those at high risk of stroke

Question 10

Importância Clínica da FA?

Answer 10

1. Perda da contratilidade auricular
2. Resposta ventricular rápida inapropriada
3. Perda da contratilidade e esvaziamento do AAE : risco de formação de trombos e eventos tromboembólicos!

Question 11

Modified EHRA score?

Answer 11

1 - AF does not cause any symptoms
2a - Normal daily activity not affected by symptoms related to AF
2b - Normal daily activity not affected by symptoms related to AF; but patient troubled by symptoms
3 - Normal daily activity affected by symptoms related to AF
4 - Normal daily activity discontinued

Question 12

Classificações de FA?

Answer 12

• • First diagnosed
• • Paroxysmal
• • Persistent
• • Long-standing persistent
• -Permanent

Question 13

CHA2DS2-VASc?

Answer 13

Congestive Heart Failure
Hypertension
Age 75y or older (2 points)
DM
Previous stroke, AIT or thromboembolism (2 points)
Vascular disease
Age 65-74y
Sex category (female)

Question 14

Diagnostic work-up ALL AF Patients?

Answer 14

Medical History
12-lead ECG
Thyroid and kidney function, electrolytes and full blood count
TTE

Question 15

Diagnostic work-up Selected AF Patients?

Answer 15

Ambulatory ECG monitoring
TEE
BNP/NT-proBNP, Cognitive function assessment
Coronary CTA or ischaemia imaging
Brain CT and MRI
LGE-CMR of the LA

Question 16

Structured follow-up?

Answer 16

To ensure continued optimal management
A cardiologist / AF specialist coordinates the follow-up in collaboration with specially trained nurses and primary care physicians

Question 17

Flutter auricular?

Answer 17

Aspeto de dente de serra - Ondas ‘F’

Question 18

Structured Characterization of AF (4S-AF)?

Answer 18

Stroke risk (CHA2DS-VASc)
Symptom severity (EHRA)
Severity of AF burden (Temporal pattern of AF and Total AF burden)
Substrate severity (comorbidities/atrial cardiomyopathy) (Clinical assessment and Imaging)

Question 19

Treat AF : ABC?

Answer 19

Anticoagulation / Avoid Stroke
Better symptom control
Comorbidities / Cardiovascular risk factor management

Question 20

Fibrilhação auricular - Objetivos do tratamento?

Answer 20

1. Controlo da FC
   - controlo da resposta V, sem o objetivo de restaurar ou manter o RS
2. Prevenção do tromboembolismo
   - tratamento antitrombótico
3. Correção da perturbação do ritmo
   - restaurar e / ou manter o RS
   - atenção ao controlo da FC
   (4. Tratamento da doença base)

Question 21

Anticoagulation / Avoid Stroke: The AF 3-step pathway?

Answer 21

Prosthetic Mechanical Heart valves or moderate-severe mitral stenosis? (Yes - AVitK)
Low stroke risk?
CHA2DS2-VASc

Question 22

Better Symptom Control: Outline of rate control therapy?

Answer 22

Heart rate < 110 bpm (12 lead ECG)
B-blockers
CCA
Digitálicos
Others (Amiodorona e Dronedarona)

Question 23

Antiarrítimicos para controlo de AF?

Answer 23

Amiodorona (mais eficaz mas mais tóxico, só se os outros não funcionarem)
Dronedarona
Flecainida
Propafenona
Sotalol

Severe HF amiodorona deve ser fármaco de escolha.

Question 24

Cardioversão / Desfribilhação?

Answer 24

Por vezes necessário na Fribrilhação Auricular
Quando hemodinamicamente instável
Quando hemodinamicamente estável verificar coagulação , hipocoagulado - Cardioversão as desired senão NOAC or LMWH and Cardioversão