AF

Question 1

What are the most common causes of AF?

Answer 1

Commonest Cause:

• Ischaemic Heart Disease
• Thyrotoxicosis
• PE

Many causes of AF (can be acute or chronic), might be unidentifiable
○ Systemic Hyperthyroidism, HTN, pneumonia, alcohol
○ Heart Mitral valve disease, ischaemic heart disease, rheumatic disease, cardiomypathy pericarditis, sick sinus syndrome, atrial myxoma
○ Lung Bronchial carcinoma, pulmonary embolism

Question 2

What are the initial considerations in management of AF?

Answer 2

1. Is the patient haemodynamically stable? No: DC cardioversion

Yes
1. Rate control
2. Rhythm Control

Question 3

What are the indications for rhythm control in AF?

Answer 3

Rate control is usually first-line exept:

• new onset with likely AF has an reversible caus
• if HF is thought to be primarily caused by AF
• new onset
• indicated by clinical judgement
• Rate-control was not successful

Therefore only really done in new-onset AF in younger patients with reversible cause

Question 4

What are the two Methods of Rythm control in AF?

Answer 4

1. Electrical DC Cardioversion: If < 48h new AF or exclusion of thrombus
2. Chemical Cardioversion (with Flecainide- contraindication: IHS –>Amiodarone)

Question 5

What are the criteria when electrical Cardioversion is considered for Rhythm control in patients with AF?

Answer 5

• If < 48h new AF:DC Cardioversion (2x100J, 1x 200J)
• If >48h 3-4 weeks of anticoagulation (Warfarin) before considering Cardioversion or TOE guided cardioversion
• Accompanied by 4 weeks pre and 12 month post- DC CV Amiodarone treatment

Question 6

What are the indications for chemical cardioversion in patients with AF?

Answer 6

Chemical Cardioversion (Flecainide- contraindication: IHS –>Amiodarone)

• 1st line: Flecainide: Sometimes patients can be eligible for Pill in the pocket Flecainide if paroxysmal AF (can be taken if palpitations commence)
• CONTRAINDICATION: structural heart disease2nd line: Amiodarone (if structural heart disease)

Question 7

Which medical agents are used first-line for Rhythm control in AF?

Answer 7

1st line:
a) Beta-blocker (e.g. Bisoprolol) - avoid if Asthma
i) Especially useful if high activated SNS. (e.g. a patient with pneumonia)

OR
CCB: Verapamil (also possible in asthmatics)

(Usually preferred way unless indication for Rhythm control)

Question 8

What are 2nd and 3rd line drugs used in rate-control for AF?

Answer 8

2) 2nd line: Digoxin(amiodarone)
a) If little/no physical exercise or
b) Heart failure
c) Other rate-limiting drugs are less preferable

3rd line: if rate-control cannot be achieved: combination of 2 of the following three
a) Beta-blocker, diltiazem, digoxin

Aim for rate of about 90

Question 9

Which elements are considered in the CHAD2VASC2 score?

Answer 9

Question 10

When should a patient with AF should be anticoagulated?

Answer 10

Depending on CHADS2VASC2 Score

In men anticoagulate if 1
In Female anticoagulation if 2

Question 11

Which score is now used to asess bleeding risk in AF?

Answer 11

Orbit

Question 12

What anticoagulation is indicated in the management for AF?

Answer 12

DOAC, e.g. Apixaban, dabigatran, edoxaban and rivaroxaban

2nd line Warfarin (only if high risk features)