In Chronic Permanent Atrial Fibrillation (AF) what are the main goals?
Rate control and Anticoagulation
When may rhythm control be appropriate, oppose to rate control?
Symptomatic, Congestive Cardiac Failure attributable, younger patients, presenting for 1st time with lone AF, AF from a correct precipitant (e.g. electrolyte imbalance)
In Chronic AF, what can you give to anticoagulate?
Warfarin, Dabigatran, Riveroxaban, Apixaban
What Scoring System is used to assess the %/year stroke risk in patients with atrial fibrillation?
What can bleeding risk in those anticoagulated with AF be assessed by?
HASBLED (or hemorr2hages)
What can be given for rate control in AF?
B-blockers, rate-limiting calcium channel blockers as first line, digoxin and even amiodarone
If a rhythm control strategy is chosen for AF, what can be given 4 weeks before cardioversion?
Sotalol or amiodarone, if there is increased risk of cardioversion failure
How can chronic AF be pharmaceutically cardioverted?
Flecainide is 1st choice if no structural heart disease, IV amiodarone if structural heart disease
What can be given for paroxysmal AF if infrequent, BP >100mmHg systolic, no past LV dysfunction?
Pill in the pocket flecainide
If AF has started in the past 48 hour, and patient is very ill or haemodynamically unstable, how should they be treated?
O2, U&Es, emergency cardioversion (electrical, if unavailable IV amiodarone) use heparin until a full risk assesment for emboli is made, control ventricular rate with verapamil (1st line) or bisoprolol. 2nd line is digoxin or amiodarone
Is a vitamin K antagonist, preventing the formation of vitamin K dependent clotting factors, X, IX, VII and II
What are possible indications for warfarin?
Prophylaxis of embolisation in rheumatic heart disease and AF, prophylaxis after mechanical heart valve, prophylaxis and treatment of venous thrombosis and PE, transient ischaemic attacks
What INR should be aimed for in atrial fibrillation?
What are contraindications to warfarin use in atrial fibrillation?
Bleeding diathesis, low platelets, consistent high blood pressure, compliance issues around dosing or INR monitoring, patient choice, frequent falls, on NSAIDs, intracranial bleeds, risk of major bleeds
Can warfarin be used in pregnancy?
Should not be given in first trimester. If at all possible, they should be avoided, especially in first and third.