Atrial Fibrillation

Introduction
Most common cardiac arrhythmia that involves the atria. In AF
the normal electrical impulses of the SA node are overwhelmed
by the disorganised impulses arising in the atria or pulmonary
veins. This disorganised electrical activity causes uncoordinated
contraction of the atria, so the atria dont function anymore as an
effective pump and instead just quiver.
Some of the impulses from the atria sporadically pass through the
AV node resulting in irregular contraction of the ventricles
thereby creating the clinical sign of an irregular pulse.
Since the atria arent pumping in a coordinated manner anymore,
there is an increased risk of developing a thrombus within the
atria, which can pass out of the heart as an embolus and cause
stroke.

Types (3 Ps)
Paroxysmal AF episodes of AF that self-terminate in <7 days
Persistent AF recurrent episodes of AF that >7 days
Permanent AF ongoing LT episode

Causes
(1)
HTN
(2)
Primary heart disease Coronary artery disease,
valve defects, hypertrophic cardiomyopathy
(3)
MI
(4)
Pneumonia
(5)
XS alcohol consumption
(6)
Hyperthyroidism
(7)
CO poisoning
(8)
+ve FHx

Signs & Symptoms

Signs tachycardia and irregularly irregular pulse
Symptoms:
(1) Palpitations
(2) Syncope
(3) Feeling faint
(4) SoB
(5) Chest pain
NB: Older patients with chronic AF are often asymptomatic

Investigations
(1)
History
(2)
Physical Examination of CVS look for irregularly irregular
pulse
(3)
ECG irregular rhythm + absent P waves
(4)
24 hr ECG tape useful to diagnose paroxysmal AF which
can be missed on routine ECG
(5)
Bloods FBC (anaemia), U&Es (electrolyte disturbance),
TFTs (thyrotoxicosis)
(6)
Echo indicated when you suspect underlying structural
heart disease or CHF or when you are considering using rhythm
control inc. electrical or pharmacological cardioversion. There are
2 types of echo: trans-thoracic echo (TTE) is 1st line and allows for
identification of structural AbN and trans-oesophageal echo (TOE)
is indicated if an AbN is detected on TTE or poor views from TTE.
Overall, look for left atrial enlargement & structural AbN.

Diagnosis
AF can be diagnosed on ECG alone with the presence of:
Irregular rhythm
Absent P waves
Although the diagnosis of AF can be made through ECG alone,
further investigation is required to find the underlying cause.

Management
Mx of AF depends largely on the type of AF the patient has.
Permanent AF - anticoagulation based on CHA2DS2-VASc score.
Rate control is used.
Rate control is needed if their:
Resting heart rate is >90 bpm (110 bpm for those with
recent onset AF)
Exercise heart rate is >200 bpm minus patients age
1st Line: blocker or rate limiting CCB
2nd Line: If resting heart rate is a problem then [
blocker or rate limiting CCB + Digoxin] OR if exercise
heart rate is the problem then [rate limiting CCB +
Digoxin]
3rd line: Amiodarone or Cardio referral
Persistent AF rate or rhythm control can be used. Rx depends
largely on individual patient factors.
Rhythm control is recommended 1st line in persistent AF
patients who are:
Symptomatic
Younger
Presenting for the first time with lone AF
Whose AF is secondary to a corrected precipitant
Have CHF
Cardioversion technique is dependent on whether the onset
of AF was <48 hrs ago or >48 hrs.
<48 hrs ago:
(1) Give heparin
(2) Perform electrical or chemical cardioversion
(Amiodarone = if structural heart disease present,
Flecainide = if not).
(3) No LT anticoagulation necessary.
>48 hrs ago:
(1) Give 3 weeks anticoagulation prior to
cardioversion OR perform TOE-guided cardioversion
(2) If patient is at high risk of cardioversion failure
(eg. Previous AF recurrence) give 4 weeks Sotalol
prior to procedure
(3) Perform electrical cardioversion
(4) Give 4 weeks anticoagulation post-procedure

(5) If patient is deemed high risk for stroke then LT

anticoagulation should be commenced with
Warfarin on an INR 2-3.
(6) Follow up patient at 1 month & 6 months postcardioversion to allow assessment of maintenance
of sinus rhythm.
Rate control is recommended 1st line in persistent AF
patients who are:
>65 y/o
Having coronary artery disease
CI to anti-arrhythmic drugs
Unsuitable for cardioversion
1st Line: blocker or rate limiting CCB
2nd Line: If resting heart rate is a problem then [
blocker or rate limiting CCB + Digoxin] OR if exercise
heart rate is the problem then [rate limiting CCB +
Digoxin]
3rd line: Amiodarone or Cardio referral
Paroxysmal AF - anticoagulation based on CHA2DS2-VASc
score. Rhythm control is used.
1st Line: Flecainide (pill in pocket approach take a tablet
when you have an episode of AF) if patient has ALL of the
following:
No LV dysfunction, valvular disease or IHD
A Hx of infrequent symptomatic episodes of
paroxysmal AF
SBP >100 mmHg and resting heart rate >70 bpm
Able to understand how and when to take medication
NB: If pill in pocket approach not suitable, try standard
blocker e.g. Atenolol
2nd Line [CAD coronary artery disease + LVD left
ventricular dysfunction]:
CAD/LVD present Sotalol
CAD/LVD absent Classic 1c agent or Sotalol (titrated
from 80mg BD to 240 mg BD)
rd
3 line Amiodarone and referral to cardio.

Anticoagulation
Assess each individual with AF to determine their stroke risk
using the CHA2DS2-VASc scoring system. Helps determine
whether anticoagulation is needed and what type to use. Max
score=9.
Aspirin no regular monitoring needed and small risk of bleeding.
Warfarin requires regular monitoring and strict control to
maintain INR at 2-3. Increased chance of bleeding esp. unsafe in
those at risk of falls. Patient education essential.
Dabigatran new generation of oral anticoagulants. Direct
thrombin inhibitor. Alternative to warfarin as it has similar efficacy
but it does not require regular monitoring of INR. No antidote
though and significantly more expensive than Warfarin even
taking into account INR monitoring.

Prognosis
Those with AF have double mortality and are at increased risk of
strokes. Prognosis largely depends on underlying medical
conditions. Any atrial arrhythmia can cause a tachycardia induced
cardiomyopathy.