ATRIAL FIBRILLATION - TOP QUESTIONS

Atrial Fibrillation
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Brief: Most common in 65+, QRS is normal. No p-waves. Fibrillation waves. Decrease in atrial function. Commonly caused by HTN, MI, LVF, CAD, Valvular disease, alcohol, thyroid. Warfarin and rate control <100 in many patients. INR 2-3. Ablation of pulmonary veins etc can yield good results in COPD patients. 

Issues: 

• Sustained vs Paroxysmal, 
• Symptomatic vs Asymptomatic - 30% are asymptomatic - screening? 
• Anticoagulants - why are they needed? What agents can be used? What is a NOAC?
• Rate control vs Rhythm control - what age groups need which? What are the clinical issues that can arise with each?
• NICE Guidelines on AF Management
• Post-operative AF - causes?
• AF in sepsis - causes? treatments?
• What investigations would you want to do? GP vs in-hospital tests?
• What pharmacological treatment is there for RATE control and RHYTHM control?
• What other treatments are available for refractory AF?
• What electrolyte imbalances cause AF?
• What serious co-morbidities can be caused by AF?
• What is CHADS2VASC? - ***KNOW THIS

Please be ready to discuss the case below/feel free to post below:
You are called to see a lady on an acute medical ward as the out of hours FY1. She is 67, in hospital with a community-acquired chest infection and has just been commenced on co-amoxiclav. The nurse has done her routine obs and found her heart rate at 150bpm. Her blood pressure is lower than earlier in the day, now sitting at 80/30 compared to 160/80. She can feel palpitations in her chest. She is pyrexic and feels tired, lethargic and is getting 'pangs' of chest pain radiating down her left arm. She tells you she has never known herself to be in AF and is on no usual medication other than her ramipril 2.5mg OD that she has been 'taking for years'. She looks unwell - she has only really arrived onto the medical assessment unit.


1. What investigations would you like to see?
2. What arrhythmia differentials come to mind with a heart rate at 150bpm, without seeing an ECG?
3. What could be causing the pain down this lady's left arm?
4. If you thought this lady was in AF - what would be your first actions? (Start as if she has not been treated by anyone else other than you)
5. What is a likely cause of this lady's tachycardia?
6. What significant co-morbidities are associated with untreated atrial fibrillation?
7. What pharmacological treatment would you consider instigating in this lady?
8. What is the effect on the heart with tachycardias with respect to cardiac output? What is the significance of diastole with respect to this?