| What symptoms can occur with rapid rate palpitations? | General fatigue or weakness or exhaustion • Dizziness, near syncope or syncope • Shortness of breath • Chest pain | SYMPTOMS - Rapid rate palpitations with or without • General fatigue or weakness or exhaustion • Dizziness, near syncope or syncope • Shortness of breath • Chest pain - More marked on exertion LOOK FOR PRECIPITATING FACTORS • Post (cardiac) surgery • Alcoholism or binge drinking • Myo-pericarditis or ACS • Pneumonitis or pulmonary embolism • Sepsis, hyperthyroidism SIGNS - Irregularly irregular pulse - Variable heart sound LOOK FOR RISK FACTORS • Prior valvular heart disease or CHF or MI • Prior TIA or stroke or embolic episode • Hypertension, DM, COPD,CKD, Obesity | 53 | list | 0.820 | SYMPTOMS - Rapid rate palpitations with or without • General fatigue or weakness or exhaustion • Dizziness, near syncope or syncope • Shortness of breath • Chest pain - More marked on exertion LOOK FOR PRECIPITATING FACTORS • Post (cardiac) surgery • Alcoholism or binge drinking • Myo-pericarditis or ACS • Pneumonitis or pulmonary embolism • Sepsis, hyperthyroidism SIGNS - Irregularly irregular pulse - Variable heart sound LOOK FOR RISK FACTORS • Prior valvular heart disease or CHF or MI • Prior TIA or stroke or embolic episode • Hypertension, DM, COPD,CKD, Obesity | 1 | page=1,block=14 | 0.700 | valid |
| What are some common risk factors for atrial fibrillation? | Prior valvular heart disease or CHF or MI • Prior TIA or stroke or embolic episode • Hypertension, DM, COPD,CKD, Obesity | SYMPTOMS - Rapid rate palpitations with or without • General fatigue or weakness or exhaustion • Dizziness, near syncope or syncope • Shortness of breath • Chest pain - More marked on exertion LOOK FOR PRECIPITATING FACTORS • Post (cardiac) surgery • Alcoholism or binge drinking • Myo-pericarditis or ACS • Pneumonitis or pulmonary embolism • Sepsis, hyperthyroidism SIGNS - Irregularly irregular pulse - Variable heart sound LOOK FOR RISK FACTORS • Prior valvular heart disease or CHF or MI • Prior TIA or stroke or embolic episode • Hypertension, DM, COPD,CKD, Obesity | 451 | list | 0.820 | SYMPTOMS - Rapid rate palpitations with or without • General fatigue or weakness or exhaustion • Dizziness, near syncope or syncope • Shortness of breath • Chest pain - More marked on exertion LOOK FOR PRECIPITATING FACTORS • Post (cardiac) surgery • Alcoholism or binge drinking • Myo-pericarditis or ACS • Pneumonitis or pulmonary embolism • Sepsis, hyperthyroidism SIGNS - Irregularly irregular pulse - Variable heart sound LOOK FOR RISK FACTORS • Prior valvular heart disease or CHF or MI • Prior TIA or stroke or embolic episode • Hypertension, DM, COPD,CKD, Obesity |
| What should be evaluated to manage the risk of stroke in patients? | stroke, bleeding risk & coagulation parameters | In all patients except hemodynamic instability Beta blocker or calcium blocker or combination BB + digoxin in HF Pharmacological Cardioversion Long Term Rhythm Control Rate aim to be less than 110/ min Hemodynamic instability Uncontrolled symptoms despite HR control Unacceptable rate control drug side effects Patients’ preference • Admit if indicators of early interventions • Immediate cardioversion after heparinization,if hemodynamic instability • Manage precipitating factors if any • Assess stroke, bleeding risk & coagulation parameters • Detailed echocardiogram • Start OAC (Oral Anticoagulant) • Control HR by single drug or combination of BB & Ca Blocker Refer HR uncontrolled or CHF or angina | 498 | list | 0.820 | In all patients except hemodynamic instability Beta blocker or calcium blocker or combination BB + digoxin in HF Pharmacological Cardioversion Long Term Rhythm Control Rate aim to be less than 110/ min Hemodynamic instability Uncontrolled symptoms despite HR control Unacceptable rate control drug side effects Patients’ preference • Admit if indicators of early interventions • Immediate cardioversion after heparinization,if hemodynamic instability • Manage precipitating factors if any • Assess stroke, bleeding risk & coagulation parameters • Detailed echocardiogram • Start OAC (Oral |
| What factors should be reassessed in patients receiving oral anticoagulants? | clinical status, need and adequacy of OAC | • Re-assess clinical status, need and adequacy of OAC • Start NOAC (Non-Vitamin K antagonist Oral Anticoagulants) • Optimise management of underlying cardiac disease • Stress life style and AF risk factor modification • Assess need for rhythm control and discuss pros & cons • Consider RFA in select patient | 12 | list | 0.820 | • Re-assess clinical status, need and adequacy of OAC • Start NOAC (Non-Vitamin K antagonist Oral Anticoagulants) • Optimise management of underlying cardiac disease • Stress life style and AF risk factor modification • Assess need for rhythm control and discuss pros & cons • Consider RFA in select patient | 1 | page=1,block=96 | 0.700 | valid |
| What factors can trigger atrial fibrillation? | Post (cardiac) surgery • Alcoholism or binge drinking • Myo-pericarditis or ACS • Pneumonitis or pulmonary embolism • Sepsis, hyperthyroidism | SYMPTOMS - Rapid rate palpitations with or without • General fatigue or weakness or exhaustion • Dizziness, near syncope or syncope • Shortness of breath • Chest pain - More marked on exertion LOOK FOR PRECIPITATING FACTORS • Post (cardiac) surgery • Alcoholism or binge drinking • Myo-pericarditis or ACS • Pneumonitis or pulmonary embolism • Sepsis, hyperthyroidism SIGNS - Irregularly irregular pulse - Variable heart sound LOOK FOR RISK FACTORS • Prior valvular heart disease or CHF or MI • Prior TIA or stroke or embolic episode • Hypertension, DM, COPD,CKD, Obesity | 226 | list | 0.780 | SYMPTOMS - Rapid rate palpitations with or without • General fatigue or weakness or exhaustion • Dizziness, near syncope or syncope • Shortness of breath • Chest pain - More marked on exertion LOOK FOR PRECIPITATING FACTORS • Post (cardiac) surgery • Alcoholism or binge drinking • Myo-pericarditis or ACS • Pneumonitis or pulmonary embolism • Sepsis, hyperthyroidism SIGNS - Irregularly irregular pulse - Variable heart sound LOOK FOR RISK FACTORS • Prior valvular heart disease or CHF or MI • Prior TIA or stroke or embolic episode • Hypertension, DM, COPD,CKD, Obesity |
| What medications should be avoided to reduce high bleeding risk? | aspirin, anti platelets, NSAIDs | • Plain X-ray chest • Thyroid evaluation • Liver function test • Troponins • Prothrombin time, INR (Coagulation profile) • Echocardiography MEASURES TO REDUCE HIGH BLEEDING RISK • Control SBP to less than 140 mmHg • Avoid dietary indiscretions • Avoid concomitant aspirin, anti platelets, NSAIDs • Avoid alcohol • Correct anemia • Detailed clinical evaluation • Basic investigations • Careful ECG evaluation • Start OAC • Start Metoprolol/Diltiazem/Verapamil if HR >110/min & no evidence of CHF • Refer if indicators for early intervention WHEN TO SUSPECT ? | 264 | list | 0.740 | • Plain X-ray chest • Thyroid evaluation • Liver function test • Troponins • Prothrombin time, INR (Coagulation profile) • Echocardiography MEASURES TO REDUCE HIGH BLEEDING RISK • Control SBP to less than 140 mmHg • Avoid dietary indiscretions • Avoid concomitant aspirin, anti platelets, NSAIDs • Avoid alcohol • Correct anemia • Detailed clinical evaluation • Basic investigations • Careful ECG evaluation • Start OAC • Start Metoprolol/Diltiazem/Verapamil if HR >110/min & no evidence of CHF • Refer if indicators for early intervention WHEN TO SUSPECT ? | 1 | page=1,block=14 |
| Which medications are suggested for pharmacological cardioversion in patients with a normal heart? | Flecainide Propafenone Sotalol | CHF CAD Abnormal LVH Amiodarone CHF Normal Heart CAD, LVH Amiodarone Flecainide Propafenone Sotalol Amiodarone Sotalol Flecainide Ibutilide Propafenone Pill in pocket (Flecainide OR Propafenone) Normal Heart Yes CHF No Symptomatic No NSR required Success- Pharmacological cardio version Yes Yes DC version Consider DC version No Clinical Follow-up Careful BB/Dig Amiodarone BB or Ca Block or combine No No Yes Yes Continue No Very rapid HR >130/ min Yes Hemodynamic Instability HR control Aim <110/min HR > 110/ min Anti-coagulants in all Except • Limited period with reversible etiology • Score <2 Confirm by 12 channel rhythm strip | 69 | list | 0.740 | CHF CAD Abnormal LVH Amiodarone CHF Normal Heart CAD, LVH Amiodarone Flecainide Propafenone Sotalol Amiodarone Sotalol Flecainide Ibutilide Propafenone Pill in pocket (Flecainide OR Propafenone) Normal Heart Yes CHF No Symptomatic No NSR required Success- Pharmacological cardio version Yes Yes DC version Consider DC version No Clinical Follow-up Careful BB/Dig Amiodarone BB or Ca Block or combine No No Yes Yes Continue No Very rapid HR >130/ min Yes Hemodynamic Instability HR control Aim <110/min HR > 110/ min Anti-coagulants in all Except • Limited period with reversible etiology • Score <2 |
| What is the duration of episodes in paroxysmal atrial fibrillation? | Episodes of AF for less than 7 days | • Paroxysmal AF: Episodes of AF for less than 7 days • Persistent AF: AF lasing from 7 days to 1 year • Long standing perssistent AF: AF lasting for > 1 year • Permanent AF: AF with heart rate control as only option LOOK FOR IMMEDIATE INTERVENTION INDICATORS • Systolic BP 90 mmHg, HR > 150 or <50/min • Ongoing Angina • CHF or TIA or stroke • Major bleed on Oral Anti-coagulants CHOICE OF ANTI-COAGULATION • Direct oral anticoagulants (DOAC) • Aim for INR 2-3 • Assess risk of bleeding • Take measures to reduce/ modify risk of bleeding • VKA only if severe M.S or metallic valve | 17 | factual | 0.570 | • Paroxysmal AF: Episodes of AF for less than 7 days • Persistent AF: AF lasing from 7 days to 1 year • Long standing perssistent AF: AF lasting for > 1 year • Permanent AF: AF with heart rate control as only option LOOK FOR IMMEDIATE INTERVENTION INDICATORS • Systolic BP 90 mmHg, HR > 150 or <50/min • Ongoing Angina • CHF or TIA or stroke • Major bleed on Oral Anti-coagulants CHOICE OF ANTI-COAGULATION • Direct oral anticoagulants (DOAC) • Aim for INR 2-3 • Assess risk of bleeding • Take measures to reduce/ modify risk of bleeding • VKA only if severe M.S or metallic valve | 1 |
| What is the management approach for permanent atrial fibrillation? | heart rate control as only option | • Paroxysmal AF: Episodes of AF for less than 7 days • Persistent AF: AF lasing from 7 days to 1 year • Long standing perssistent AF: AF lasting for > 1 year • Permanent AF: AF with heart rate control as only option LOOK FOR IMMEDIATE INTERVENTION INDICATORS • Systolic BP 90 mmHg, HR > 150 or <50/min • Ongoing Angina • CHF or TIA or stroke • Major bleed on Oral Anti-coagulants CHOICE OF ANTI-COAGULATION • Direct oral anticoagulants (DOAC) • Aim for INR 2-3 • Assess risk of bleeding • Take measures to reduce/ modify risk of bleeding • VKA only if severe M.S or metallic valve | 182 | factual | 0.570 | • Paroxysmal AF: Episodes of AF for less than 7 days • Persistent AF: AF lasing from 7 days to 1 year • Long standing perssistent AF: AF lasting for > 1 year • Permanent AF: AF with heart rate control as only option LOOK FOR IMMEDIATE INTERVENTION INDICATORS • Systolic BP 90 mmHg, HR > 150 or <50/min • Ongoing Angina • CHF or TIA or stroke • Major bleed on Oral Anti-coagulants CHOICE OF ANTI-COAGULATION • Direct oral anticoagulants (DOAC) • Aim for INR 2-3 • Assess risk of bleeding • Take measures to reduce/ modify risk of bleeding • VKA only if severe M.S or metallic valve | 1 |
| When should VKA be used instead of direct oral anticoagulants? | only if severe M.S or metallic valve | • Paroxysmal AF: Episodes of AF for less than 7 days • Persistent AF: AF lasing from 7 days to 1 year • Long standing perssistent AF: AF lasting for > 1 year • Permanent AF: AF with heart rate control as only option LOOK FOR IMMEDIATE INTERVENTION INDICATORS • Systolic BP 90 mmHg, HR > 150 or <50/min • Ongoing Angina • CHF or TIA or stroke • Major bleed on Oral Anti-coagulants CHOICE OF ANTI-COAGULATION • Direct oral anticoagulants (DOAC) • Aim for INR 2-3 • Assess risk of bleeding • Take measures to reduce/ modify risk of bleeding • VKA only if severe M.S or metallic valve | 544 | factual | 0.570 | • Paroxysmal AF: Episodes of AF for less than 7 days • Persistent AF: AF lasing from 7 days to 1 year • Long standing perssistent AF: AF lasting for > 1 year • Permanent AF: AF with heart rate control as only option LOOK FOR IMMEDIATE INTERVENTION INDICATORS • Systolic BP 90 mmHg, HR > 150 or <50/min • Ongoing Angina • CHF or TIA or stroke • Major bleed on Oral Anti-coagulants CHOICE OF ANTI-COAGULATION • Direct oral anticoagulants (DOAC) • Aim for INR 2-3 • Assess risk of bleeding • Take measures to reduce/ modify risk of bleeding • VKA only if severe M.S or metallic valve | 1 |