E123yfhfhhfhf1232 Guideliens 332133

ATRIAL FIBRILLATION 2
Atrial Fibrillation  Loss of atrial contraction → No “a” wave in JVP,

no S4
Pathophysiology Investigations
 Chaotic, irregular atrial rhythm at 300-600 bpm  ECG – absent P waves, irregularly irregular,
 AV node responds intermittently → irregular narrow QRS; wide QRS due to aberrancy
ventricular rhythm → CO↓ by 10-20% (Ashman phenomenon)
 Incidence ↑ with age (10%>age 80)  Blood tests – U&E, TSH, T-T/I, CKMB
 Echo – LA enlargement, MV pathology, poor LV
Aetiology function
 HF, HTN, IHD (22% MI patients), MS/R Acute AF management (RACE)
 PE, Pneumonia
 Hyperthyroidism, ↓K+, ↓Mg2+  If adverse signs (shock, chest pain, ECG ∆,
 Caffeine, alcohol, post-op syncope, HF) → (ABCDE + senior → DC
 Rare: cardiomyopathy, constrictive pericarditis, cardioversion (synchronised shock; start 120-150
sick sinus syndrome, lung cancer, endocarditis, J) ± amiodarone if unsuccessful)
haemochromatosis, sarcoid  If stable + AF started <48hrs → rhythm control
(DC CV or flecainide [CI: structural heart disease,
Classification IHD] or amiodarone); if CV delayed start heparin
 If stable + >48hrs → rate control (e.g. bisoprolol,
 Lone AF – no cause found; <age 60 diltiazem, B-blockers, verapamil); if rhythm
Non-valvular – not due to valvular pathology, control chosen, patient must be anticoagulated
prosthetic valve, valve repairAetiology for 3wk prior, 4wk post
 Correct E imbalance (K, Mg, Ca); etiology;
 HF, HTN, IHD (22% MI patients), MS/R consider anticoagulation
 PE, Pneumonia
 Hyperthyroidism, ↓K+, ↓Mg2+ Chronic AF management
 Caffeine, alcohol, post-op
 Rare: cardiomyopathy, constrictive pericarditis,  Main goals: rate control, anticoag
sick sinus syndrome, lung cancer, endocarditis,  Rhythm control appropriate if symptomatic or
haemochromatosis, sarcoid CCF, younger, 1st presentation with lone AF, AF
from corrected precipitant (U&E)
Classification  Rate control – B-blocker or rate-limiting Ca2+
blocker 1st line → if fail, add digoxin
 Lone AF – no cause found; <age 60 (monotherapy only in sedentary patients
 Non-valvular – not due to valvular pathology,  Paroxysmal – episodes that terminate
prosthetic valve, valve repair spontaneously
 Paroxysmal – episodes that terminate  Persistent – sustain >7day or terminate only with
spontaneously cardioversion
 Persistent – sustain >7day or terminate only with  Permanent/chronic – continuous with
cardioversion unresponsive to cardioversion or cardioversion
 Permanent/chronic – continuous with not recommended
unresponsive to cardioversion or cardioversion  Recurrent – ≥2episodes
not recommended  Secondary – due to underlying condition (MI,
 Recurrent – ≥2episodes surgery, pulmonary, hyperthyroidism)
 Secondary – due to underlying condition (MI,  Associated with thromboembolic events (assess
surgery, pulmonary, hyperthyroidism) stroke risk by CHADS2 score in non-valvular AF
 Associated with thromboembolic events (assess → if 0/1 → CHAD2DS2-VASc)
stroke risk by CHADS2 score in non-valvular AF
→ if 0/1 → CHAD2DS2-VASc) Symptoms
Symptoms  Asymptomatic
Chest pain, palpitation, SOB, faintnessAetiology
 Asymptomatic
 Chest pain, palpitation, SOB, faintness  HF, HTN, IHD (22% MI patients), MS/R
 PE, Pneumonia
Signs  Hyperthyroidism, ↓K+, ↓Mg2+
 Caffeine, alcohol, post-op
 Irregularly irregular pulse  Rare: cardiomyopathy, constrictive pericarditis,
 Pulse deficit sick sinus syndrome, lung cancer, endocarditis,
 S1 of variable intensity haemochromatosis, sarcoid
 Signs of LVF
Classification  Rate control – B-blocker or rate-limiting Ca2+
blocker 1st line → if fail, add digoxin
 Lone AF – no cause found; <age 60 (monotherapy only in sedentary patients
 Non-valvular – not due to valvular pathology, Signs
prosthetic valve, valve repair
 Paroxysmal – episodes that terminate  Irregularly irregular pulse
spontaneously  Pulse deficit
 Persistent – sustain >7day or terminate only with  S1 of variable intensity
cardioversion  Signs of LVF
 Permanent/chronic – continuous with  Loss of atrial contraction → No “a” wave in JVP,
unresponsive to cardioversion or cardioversion no S4
not recommended
 Recurrent – ≥2episodes
 Secondary – due to underlying condition (MI, Investigations
surgery, pulmonary, hyperthyroidism)
 Associated with thromboembolic events (assess  ECG – absent P waves, irregularly irregular,
stroke risk by CHADS2 score in non-valvular AF narrow QRS; wide QRS due to aberrancy
→ if 0/1 → CHAD2DS2-VASc) (Ashman phenomenon)
 Blood tests – U&E, TSH, T-T/I, CKMB
Symptoms  Echo – LA enlargement, MV pathology, poor LV
function
 Asymptomatic
 Chest pain, palpitation, SOB, faintness Acute AF management (RACE)
Signs  If adverse signs (shock, chest pain, ECG ∆,

syncope, HF) → (ABCDE + senior → DC
 Irregularly irregular pulse cardioversion (synchronised shock; start 120-150
 Pulse deficit J) ± amiodarone if unsuccessful)
 S1 of variable intensity  If stable + AF started <48hrs → rhythm control
 Signs of LVF (DC CV or flecainide [CI: structural heart disease,
 Loss of atrial contraction → No “a” wave in JVP, IHD] or amiodarone); if CV delayed start heparin
no S4  If stable + >48hrs → rate control (e.g. bisoprolol,
diltiazem, B-blockers, verapamil); if rhythm
control chosen, patient must be anticoagulated
Investigations for 3wk prior, 4wk post
 ECG – absent P waves, irregularly irregular, consider anticoagulation
narrow QRS; wide QRS due to aberrancy
(Ashman phenomenon) Chronic AF management
 Blood tests – U&E, TSH, T-T/I, CKMB
 Echo – LA enlargement, MV pathology, poor LV  Main goals: rate control, anticoag
function  Rhythm control appropriate if symptomatic or
CCF, younger, 1st presentation with lone AF, AF
Acute AF management (RACE) from corrected precipitant (U&E)
 Rate control – B-blocker or rate-limiting Ca2+
 If adverse signs (shock, chest pain, ECG ∆, blocker 1st line → if fail, add digoxin
syncope, HF) → (ABCDE + senior → DC (monotherapy only in sedentary patients)
cardioversion (synchronised shock; start 120-150
J) ± amiodarone if unsuccessful)
 If stable + AF started <48hrs → rhythm control
(DC CV or flecainide [CI: structural heart disease,
IHD] or amiodarone); if CV delayed start heparin
 If stable + >48hrs → rate control (e.g. bisoprolol,
diltiazem, B-blockers, verapamil); if rhythm
control chosen, patient must be anticoagulated
for 3wk prior, 4wk post
consider anticoagulation
Chronic AF management
 Main goals: rate control, anticoag

 Rhythm control appropriate if symptomatic or
CCF, younger, 1st presentation with lone AF, AF
from corrected precipitant (U&E)

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E123yfhfhhfhf1232 Guideliens 332133

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ATRIAL FIBRILLATION 2

Atrial Fibrillation  Loss of atrial contraction → No “a” wave in JVP,

Signs  If adverse signs (shock, chest pain, ECG ∆,

 Main goals: rate control, anticoag

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