As a Cardiology fellow, we get a lot of consults for atrial fibrillation.
Here is my approach/work-up for this consult.
*Not to use as medical advice, just tips, and always discuss with your fellow/attending*
-thread ๐งต-
#MedTwitter #MedEd #Cardiotwitter #IMG
Here is my approach/work-up for this consult.
*Not to use as medical advice, just tips, and always discuss with your fellow/attending*
-thread ๐งต-
#MedTwitter #MedEd #Cardiotwitter #IMG
Background:
- Most common sustained cardiac arrhythmia (1/3 of hospitalizations for cardiac disturbances)
- Degeneration of organized atrial electrical activity into a rapid, chaotic pattern.
- Increases risk of stroke, heart failure, and mortality; higher incidence M >W
- Most common sustained cardiac arrhythmia (1/3 of hospitalizations for cardiac disturbances)
- Degeneration of organized atrial electrical activity into a rapid, chaotic pattern.
- Increases risk of stroke, heart failure, and mortality; higher incidence M >W
Classification System:
1) Paroxysmal: Self-limiting
2) Persistent: > 7 days
3) Long-standing persistent > 12 months
4) Permanent: No longer pursuing restoration of NSR
5) Valvular: Rheumatic MS, Prosthetic Valve, or Mitral valve repair
6) Non-Valvular
1) Paroxysmal: Self-limiting
2) Persistent: > 7 days
3) Long-standing persistent > 12 months
4) Permanent: No longer pursuing restoration of NSR
5) Valvular: Rheumatic MS, Prosthetic Valve, or Mitral valve repair
6) Non-Valvular
Pathophysiology:
- Multiple disease pathways that are not fully understood
- Thought to be due to increased automaticity and re-entrant wavelets that occur in the left atrium around the pulmonary veins.
- Modulating factors: autonomic tone, medications, atrial pressure
- Multiple disease pathways that are not fully understood
- Thought to be due to increased automaticity and re-entrant wavelets that occur in the left atrium around the pulmonary veins.
- Modulating factors: autonomic tone, medications, atrial pressure
Risk Factors:
- Advanced age
- HTN
- Valvular Heart Disease
- CAD
- HF
- Physiological stress
- Drugs
- PE
- Hyperthyroidism
- Infectious processes
- Metabolic disturbances
- Obesity
- OSA
- Post-Cardiac Surgery
- Advanced age
- HTN
- Valvular Heart Disease
- CAD
- HF
- Physiological stress
- Drugs
- PE
- Hyperthyroidism
- Infectious processes
- Metabolic disturbances
- Obesity
- OSA
- Post-Cardiac Surgery
Clinical Presentation:
- Can be asymptomatic
- Symptoms: palpitations, fatigue, dyspnea, syncope, stroke
Diagnostic Testing:
- CBC, CMP, Mg, TSH/T4, 12-lead EKG (f-waves)
- TTE to rule out structural heart disease, asses LV function, and document co-existent PHTN
- Can be asymptomatic
- Symptoms: palpitations, fatigue, dyspnea, syncope, stroke
Diagnostic Testing:
- CBC, CMP, Mg, TSH/T4, 12-lead EKG (f-waves)
- TTE to rule out structural heart disease, asses LV function, and document co-existent PHTN
Thromboembolic Risk Assessment (CHA2DS2-VASC)
- Heart Failure: 1
- HTN: 1
- Age โฅ 75: 2
- Diabetes: 1
- Systemic Thromboembolism: 2
- Vascular Disease: 1
- Age 64-74: 1
- Female Sex: 1
In men with โฅ 2 or female โฅ3 should start AC (unless contraindication); use HAS-BLED
- Heart Failure: 1
- HTN: 1
- Age โฅ 75: 2
- Diabetes: 1
- Systemic Thromboembolism: 2
- Vascular Disease: 1
- Age 64-74: 1
- Female Sex: 1
In men with โฅ 2 or female โฅ3 should start AC (unless contraindication); use HAS-BLED
Rate Control:
- BB: (Oral/IV forms): Can use Metoprolol Succinate, Carvedilol, Bisoprolol if concomitant LV dysfunction
- Non-Dihydropyridine Ca2+ blockers: Diltiazem & Verapamil (Rapid onset of action; should not use in decompensated HF or cardiac amyloidosis)
- BB: (Oral/IV forms): Can use Metoprolol Succinate, Carvedilol, Bisoprolol if concomitant LV dysfunction
- Non-Dihydropyridine Ca2+ blockers: Diltiazem & Verapamil (Rapid onset of action; should not use in decompensated HF or cardiac amyloidosis)
Rate Control:
- Digitalis (Oral/IV forms): used primarily when contraindication for BB or Ca2+ blocker in patients with LV dysfunction; can be used as adjunct therapy. Monitor for toxicity.
- Amiodarone: Patients must be anticoagulated; chance of pharmacological cardioversion!
- Digitalis (Oral/IV forms): used primarily when contraindication for BB or Ca2+ blocker in patients with LV dysfunction; can be used as adjunct therapy. Monitor for toxicity.
- Amiodarone: Patients must be anticoagulated; chance of pharmacological cardioversion!
Rhythm Control:
- Unstable: should have a TEE-DCCV
- Flecainide ('pill in pocket,' not used with CAD, LV dysfunction, or significant heart disease)
- Dofetilide (need QT prolongation monitoring, can cause Torsades)
- Can have a radiofrequency ablation/Maze procedure
- Unstable: should have a TEE-DCCV
- Flecainide ('pill in pocket,' not used with CAD, LV dysfunction, or significant heart disease)
- Dofetilide (need QT prolongation monitoring, can cause Torsades)
- Can have a radiofrequency ablation/Maze procedure
Unique Populations:
- Hypertrophic CM: Should be anti-coagulated regardless of CHA2DS2-VASC; BB is good to increase the diastolic filling time
- Pulmonary disease: AF is common in patients with COPD; should treat underlying lung disease of hypoxia and acid-base disorders
- Hypertrophic CM: Should be anti-coagulated regardless of CHA2DS2-VASC; BB is good to increase the diastolic filling time
- Pulmonary disease: AF is common in patients with COPD; should treat underlying lung disease of hypoxia and acid-base disorders
Remember is a very common diagnosis seen both in the inpatient and clinic setting. The biggest strategies are rate control (<110) to prevent tachycardia-induced cardiomyopathy or stroke (through AC).
If you would be interested in a PDF of my threads, let me know below! ๐
If you would be interested in a PDF of my threads, let me know below! ๐
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