Atrial fibrilation
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ATRIAL FIBRILATION. Raj Chahal. First Steps. CONFIRM DIAGNOSIS (ECG) IMMEDIATE RESUSCITAION AIRWAY BREATHING CIRCULATION HAEMODYNAMIC PROFILE HEART RATE BLOOD PRESSURE. TYPES. PERMANENT PERSISTENT PAROXYSMAL. AF WITH FAST VENTRICULAR RATE AF WITH APPROPRIATE RATE. UNSTABLE.

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ATRIAL FIBRILATION

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Atrial fibrilation

ATRIAL FIBRILATION

Raj Chahal


First steps

First Steps

  • CONFIRM DIAGNOSIS (ECG)

  • IMMEDIATE RESUSCITAION

  • AIRWAY

  • BREATHING

  • CIRCULATION

  • HAEMODYNAMIC PROFILE

    • HEART RATE

    • BLOOD PRESSURE


Types

TYPES

  • PERMANENT

  • PERSISTENT

  • PAROXYSMAL


Atrial fibrilation

  • AF WITH FAST VENTRICULAR RATE

  • AF WITH APPROPRIATE RATE


Unstable

UNSTABLE

  • HYPOTENSIVE

  • CHEST PAINS

  • Consider reversible causes

    • Haemorrhage

    • PE

  • Call senior help and consider emergency DCCV under sedation.


Stable

STABLE

  • History and Examination

  • Confirm diagnosis

  • Consider exacerbating causes

  • Stroke risk assessment

  • Rate or Rhythm control


Exacerbating causes

Exacerbating Causes

  • Infection

  • Hyperthyroidism

  • Alcohol

  • Caffeine

  • Surgery

  • Ischaemia


Stroke risk assessment

Stroke Risk Assessment

  • CHADS2 SCORE

    • Cardiac Failure

    • Hypertension

    • Age over 75

    • Diabetes

    • Stroke/TIA (2)

      0-Aspirin alone

      1-Aspirin or Warfarin

      ≥2-Warfarin

      Consider patient choice and logistics/safety of warfarin


Rate or rhythm control

Rate or Rhythm Control


Try rhythm control first for patients with persistent af

Try rhythm-control first for patientswith persistent AF:

  • who are symptomatic

  • who are younger

  • presenting for the first time with lone AF

  • secondary to a treated or corrected precipitant

  • with congestive heart failure.

  • CARDIOVERSION FROM AF

  • MAINTENANCE OF SR


Try rate control first for patients with persistent af

Try rate-control first for patients with persistent AF:

  • over 65

  • with coronary artery disease

  • with contraindications to antiarrhythmic drugs

  • unsuitable for cardioversion


Practicalities

Practicalities

  • On initial assessment on finding AF before deciding on aspirin or warfarin

    • GIVE THERAPEUTIC DOSE LMWH DALTPARIN (FRAGMIN) unless contraindicated


Rhythm control cardioversion

Rhythm Control - cardioversion

  • Consider onset

    • <48 hours

    • >48 hours

  • If less than 48 hours then less chance of thrombus formation.

  • IV amiodorone 300mg over 1 hour

  • IV amiodorone 900-1200mg over 23 hours

  • DCCV under sedation


Atrial fibrilation

  • If greater than 48 hours

  • Warfarin for 3-6 weeks

  • Request echo

  • Request DCCV

  • Continue warfarin for 4 weeks post

  • In high risk of recurrence, continue warfarin


Rhythm control maintenance

RHYTHM CONTROL – maintenance

  • When back in SR consider medication to maintain in SR.

  • Oral amiodarone (remember counselling & monitoring)

    • 200mg tds 1/52; 200mg bd 1/52; 200mg od thereafter

  • If no structural heart disease:

  • Oral flecainide

  • Oral sotalol

  • Oral propafenone


Rate control

RATE CONTROL

  • In permanent AF

  • Left atrial enlargement

  • AF over year

  • Recurrent AF

  • Use beta-blocker (bisoprolol) or rate limiting calcium channel blocker (diltiazem)

  • Further rate control can be gained with digoxin and amiodarone


Follow up

FOLLOW UP

  • In those with rhythm control check with 24 hour ECG as OP after 4/52


Questions

Questions?


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