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BODY SYSTEMS HISTORY TAKING OSCE CLINICAL CASES PHARMACOLOGY QUIZ

ADDED OCT 12, 2010, UNDER: CARDIOLOGY

What is Atrial Fibrillation?

Atrial Fibrillation (AF) is the most common cardiac arrythmia and involves the upper two chambers of the hear (atria). In AF the normal electrical impulses of the sino-atrial node are overwhelmed by disorganised impulses arising in the atria or pulmonary veins. This disorganised electrical activity causes uncoordinated contraction of the atria which results in the atria no longer functioning as an effective pump & instead just quivering Some of the impulses from the atria sporadicallty pass through the atrio-ventricular node and result in irregular contraction of the ventricles. Because the atria are no longer effectively pumping, there is an increased risk of developing a thrombus within the atria, which can then pass out of the heart and cause a stroke. As a result atrial fibrillation is a serious medical condition that should treated to prevent serious harm or death of a patient.

Causes
Hypertension Primary Heart Disease coronary artery disease, valve defects, hypertrophic cardiomyopathy Myocardial Infarction Pneumonia Excessive alcohol consumption Hyperthyroidism Carbon Monoxide Poisoning Family History

Signs& Symptoms
Signs
Tachycardia Irregularly Irregular Pulse

Symptoms

Palpitations Syncope Feeling faint SOB Chest Pain Older patients with chronic AF are often asymptomatic

Investigations
Thorough History - onset, duration, associated symptoms Cardiovascular Examination ECG Echocardiogram look for left atrial enlargement & strucural abnormalities Bloods - electrolyte disturbance, renal function, thyroid function (thyrotoxicosis), FBC (anaemia)

Diagnosis
ECG - absent P waves, irregular QRS complexes

Management
Acute Atrial Fibrillation
Treat associated illness Control ventricular rate Verapamil (1st line in acute) Start Anticoagulation Heparin 5000-10,000 units IV . Cardioversion

Chemical Cardioversion Flecainide Electro-Cardioversion Patient must be anti-coagulated if within 48hrs of onset of AF

Chronic Atrial Fibrillation

Rate control Beta-Blocker - Atenolol Ca+ channel blocker Verampimil Cardiac Glycoside Amiodarone Rhythm Control Chemical Cardioversion - Amiodarone Electrical Cardioversion not usually useful in chronic AF as relapse

. Anticoagulation Warfarin

Aim to keep INR between 2-3 Use of warfarin depends upon CHADS score Chads score of >2 means start warfarin unless contraindicated Reduces absolute risk of stroke (1-12%) by 64% Requires regular monitoring & strict control - unpredictable Increased chance of bleeding over aspirin (1.8% vs 0.8%) Not safe in those at risk of falls Good patient education is essential

. Aspirin Chads score of <2 Reduces absolute risk of stroke by 22% No regular monitoring required as predictable Very small chance of bleeding (0.8%)

Prognosis
Double the mortality of those without atrial fibrillation 4 to 5 fold higher risk of stroke than those without fibrillation. Prognosis depends on the patients underlying medical condition. Any atrial arrhythmia can cause a tachycardia-induced cardiomyopathy