"ATRIAL FIBRILLATION AND STROKE PREVENTION" –

The prevalence of atrial fibrillation is increasing due to an ageing population. This is the most common
arrhythmia encountered in clinical practice. The socioeconomic burden of A fib is around £500 million a
year of total NHS expenditure (a huge some of money!). In the USA the estimated total annual cost of
treating atrial fibrillation amounts to about $6.65 billion!! This is why its an absolute must know for all
doctors starting training in UK.

QUESTION 1)

Which one of the following statements about the epidemiology of atrial fibrillation is correct?

A. The prevalence of atrial fibrillation is decreasing with improvements in medical care and
treatment methods
B. The prevalence of atrial fibrillation increases with age
C. Women are twice as likely as men to develop atrial fibrillation
D. The risk of embolic stroke is doubled in presence of atrial fibrillation

( The answer is indeed B - The prevalence of atrial fibrillation is increasing reflecting the growing
number of elderly people in the population. Men are 1.5 times more likely than women to develop atrial
fibrillation. The risk of embolic stroke increases fivefold in the presence of atrial fibrillation
Atrial fibrillation is the most commonly encountered arrhythmia in clinical practice and is associated
with increased morbidity and mortality e.g. from STROKE and HEART FAILURE
AF increases with age up to 18% in ppl older than 85
It is more common in males)

QUESTION 2) TOUGH QUESTION AS DEFINITIONS OF A FIB ARE DIFFICULT

Which one of the following statements about atrial fibrillation is correct?

A. Atrial fibrillation is classified as persistent when all attempts to restore sinus rhythm have
failed
B. The longer the duration of atrial fibrillation, the more difficult it becomes to restore sinus
rhythm
C. Valvular heart disease (for example mitral regurgitation) is the most common cause of atrial
fibrillation in the UK
D. Atrial fibrillation is classified as permanent when arrhythmia has persisted >7days, is not self-
terminating, and pharmacological or electrical cardioversion is required to restore sinus rhythm.

 The longer the duration of A fib the more difficult it becomes to restore sinus rhythm - this is
due to electrical and structural remodelling of the atrial tissue. In developed nations most atrial
fibrillation occurs in patients with a background of HYPERTENSION AND ISCHAEMIC HEART
DISEASE (so C is wrong)
  Number 1 cause in UK = systemic hypertension; number 1 cause in developing countries =
rheumatic valvular disease
 Now for the definitions: SILENT AF = asymptomatic and picked up incidentally
 Paroxysmal AF = Recurrent self-terminating and short duration episodes (usually minutes to
hours) but <7days (most terminate within 48hours)
 Persistent AF = Arrhythmia lasting >7days. Not self-terminating, and pharmacological or
electrical cardioversion is required to restore sinus rhythm (therefore A is wrong because in
persistent AF attempts are made at restoring sinus rhythm).
 Permanent AF = no further attempts at terminating the arrhythmia are planned because all
attempts have failed (so answer D and A need to be switched around in order to be correct)
 Lone" or idiopathic AF = AF occurs in a normal heart and no other underlying conditions
predisposing to AF

QUESTION 3)

Which one of these investigations must be undertaken for ALL patients with suspected AF?
A. Thyroid function tests
B. Transthoracic echocardiogram
C. Electrocardiogram
D. Transoesophageal echocardiogram
E. HbA1c

 the answer is unequivocally C - suspecting AF is not the same as diagnosing (and documenting)
AF. The ECG is required for diagnosis.
 An irregular pulse detected by manual palpation should be followed by an ECG to confirm the
diagnosis. It is also important to establish whether the patient is stable or unstable,
symptomatic or asymptomatic, and what may be causing the AF. Further investigations (such as
thyroid function tests, HbA1c, or a transthoracic echocardiogram) may be needed depending on
the clinical situation. For example a transthoracic echocardiogram is NOT needed in every
patient....A elderly man is found to have asymptomatic A fib and no cardiovascular risk
factors..in this patient a transthoracic echo is a waste of money as this patient most likely will
not receive any medication and even if he does he will receive RATE CONTROL (doesn't need an
ech)
 UNSTABLE = chest pain (angina), low BP, altered mental status, dyspnoea
 In short: Irregular pulse detected on manual palpation + characteristic ECG = A fib.
 QUICK NOTE: Transthoracic echocardiogram..when to order? when there is a suspicion of an
underlying structural or functional heart disease (such as heart failure or heart murmur)
If a rhythm control strategy that includes cardioversion is being considered (rhythm control is
NOT used in all patients therefore it was the wrong answer)
  When to order TRANSOESOPHAGEAL ECHOCARDIOGRAM? transthoracic echocardiogram
detects an abnormality that requires further assessment (remember TOE gives a much better
view of left atrium)

QUESTION 5) FINALLY LETS TRY MANAGE A PATIENT WITH A FIB!

A 76 year old Asian man presents to his GP with a two-day history of malaise, shortness of
breath, and dizziness. He has a previous medical history of hypertension, angina, and diabetes
mellitus. On examination, his pulse is 156 bpm and irregular, his blood pressure is 89/54 mm Hg,
he feels dizzy on standing, and is short of breath. What is the most appropriate initial
management option?
A. Arrange an ECG to confirm a diagnosis of AF
B. Discuss starting rate control medication
C. Discuss stroke risk and anticoagulation
D. Discuss starting rhythm control medication
E. Refer for same day medical assessment

 Not an easy question. On first glance it seems as though this patient needs an ECG and
confirmation of AF (answer A), however, the location of the patient is extremely important (GP -
primary care), and although GP surgeries may have an ECG machine, an unstable patient must
NOT EVER wait for an ECG in a primary care setting. He must be referred the same day for
secondary care medical assessment and there he will have an ECG and further managment will
be instilled. So E is the answer.
 The clinical suspicion for AF is so high in this patient, doing an ECG in the office would be a
complete waste of time because the GP would have no management options for the patient. He
will be taken (maybe by ambulance where an ECG can be performed anyway) to the hospital
and the secondary care that this patient requires will be initiated . this is a problem out of the
hands of a GP in primary care

QUESTION 4)

Which one of the following features is characteristic of atrial fibrillation?

A. Symptoms of palpitations and breathlessness in most patients

B. Irregularly irregular pulse in every patient
C. Absence of atrial waves on the ECG
D. Presence of sawtooth appearance on the ECG
E. Polymorphic ventricular tachyarrhythmia on ECG
  I mentioned in the previous question that irregular pulse + characteristic ECG = A
fib (now this is 100% true), however there are occasions were the pulse in a
patient may actually be normal. A regular pulse rate is possible when impulses are
unable to pass through the AV node (for whatever reason e.g. due to degeneration
in old age). If none of the impulses pass from the extremely "excited" atria to the
ventricles, the ventricles contract independently and autonomously which may
result in a regular rate. Hence B is incorrect because NOT ALL PATIENTS
WITH A FIB HAVE IRREGULAR PULSES (now for your PLAB 1 exam, the
pulse will be irregular, but im trying to make you all better than learning just the
ABC)
 A is completley wrong - majority of patients, especially elderly people, can be
totally asymptomatic and yet have atrial fibrillation
 C - Atrial fibrillation is a supraventricular arrhythmia characterised by complete
absence of coordinated atrial contractions.
ECG - P waves are absent (hence C is correct by definition) and are replaced by
fibrillatory waves and an irregular ventricular response is also usually seen with a
variable time between QRS complexes.
 D - is atrial flutter
 E - occurs usually on the background of prolonged QT interval (which is caused
by many antiarrhythmic drugs which we will discuss when we get to
management)
 KEY POINT FOR PATIENTS WITH SUSPECTED PAROXYSMAL AF: they
may have a normal ECG. You must then perform:
- 24-hour ambulatory ECG monitor if symptomatic episodes are less than 24
hours apart.
- An event recorder ECG if symptomatic episodes more than 24 hours apart.

QUESTION 6)

Which one of the following statements about managing a patient with atrial fibrillation is
correct?
A. If a patient presents to the emergency department with atrial fibrillation the main priority is to
restore sinus rhythm
B. The risk of thromboembolism is minimal if cardioversion is attempted within seven days of
onset of atrial fibrillation
C. The risk of thromboembolism is less with pharmacological cardioversion than with direct
current cardioversion
D. It may be best to accept the arrhythmia as permanent in relatively asymptomatic elderly
patients even when atrial fibrillation is first diagnosed
  The answer here is D - It may be best to accept the arrhythmia as permanent in elderly
patients who are relatively asymptomatic. Usually elderly patients don't require any
treatment for there A fib if asymptomatic (=permanent A fib)
 A - is wrong - The main priority is rate control, provided the haemodynamic status of the
patient is stable. In unstable patients with low BP - urgent direct current cardioversion is
indicated. Cardioversion in the emergency department may be appropriate if the
arrhythmia has been present for less than 48 hours
 B - The risk of thromboembolism is minimal if cardioversion is attempted within 48
HOURS of onset of atrial fibrillation
 C - the risk of thromboembolism is the same regardless of the method of cardioversion
 Yes I said permanent atrial fibrillation is when all therapies fail, BUT if an elderly
asymptomatic patient presents with AF this is also regarded as permanent as technically
no medical therapy will be given to him.And if no medical therapy is given to a patient
with AF, then it is described as permenant - therefore D is the answer

QUESTION 10)
A 69 year old accountant is diagnosed with AF after presenting with a six month history of palpitations.
He has hypertension, asthma, and coeliac disease. His current medications include ramipril, salbutamol,
and a fluticasone/salmeterol combination inhaler. What is the most suitable first line management for
symptom control?
A. Bisoprolol
B. Referral for cardioversion
C. Diltiazem
D. Digoxin
E. Flecainide

 Beta-blockers can induce asthma. Bisoprolol has less effect on the β2 receptors and is
therefore, relatively cardioselective, but is not cardiospecific. It has a lesser effect on
airways, but is not free of this side effect, particularly at higher dosages therefore In this
patient it is wiser to use diltiazem as rate control
 he patient is not unstable therefore cardioversion is unnecessary
 Digoxin is reserved for sedentary patients or those with heart failure
 Flecainide is for pharmacological cardioversion and more importantly prevention of
recurrences in patients who have been cardioverted back into sinus rhythm
 By sedentary I mean, completley no exercise or anything. We can't assume that this
patient is sedentary based on his occupation of accountancy. So digoxin is not a good
enough answer in this case. If BB are contraindicated then pick a CCB
 Pick digoxin when there is concomitant heart failure and AF or when they specifically
say that he is completley sedentary and inactive.OK
QUESTION 8)

Which one of the following statements about amiodarone is correct?

A.You can prescribe it in patients with ischaemic heart disease, heart failure, or
ventricular hypertrophy
B. It is used mainly as a rate controlling agent
C. It rarely affects the thyroid gland
D. It has no effect on the heart rate

 The answer here is A (refer to last question - any patient with heart disease, amiodarone is the
drug of choice for ryhthm control). Amiodarone - drug of choice in patients with ventricular
dysfunction (i.e. heart failure) and ischaemic heart disease. Amiodarone also has an added
advantage of providing prompt rate control (early effect following IV loading) in addition to its
antiarrhythmic effect (8-24hrs).
Intravenous amiodarone should be administered preferably via a central vein or through a large
peripheral vein to prevent phlebitis. Most of the toxicity of amiodarone is dose dependent and
related to chronic treatment. Amiodarone should still be used with caution in patients with
acute ischaemia or myocardial dysfunction because profound hypotension may be induced by
intravenous or high dose oral loading.
 B - is wrong because even though it has rate-controlling properties it is first and foremost a class
III antiarrhythmic drug
 Long term use can lead to both hyperthyroidism and hypothyroidism, bluish discoloration of the
skin, pulmonary fibrosis (may require regular lung function tests), liver damage (regular LFTs)

QUESTION 9) - IMPORTANT QUESTION!

Which one of the following statements about the pharmacological treatment of atrial fibrillation
is correct?

A. Pharmacological cardioversion is usually successful if initiated within six weeks of the onset
of atrial fibrillation
B. Sotalol and digoxin are agents used for acute pharmacological cardioversion
C. The incidence of sustained or fatal polymorphic ventricular tachycardia (torsades de pointes)
is increased during treatment with sotalol (QT prolongation), class Ia (QT or QRS prolongation)
and class Ic (QRS prolongation) antiarrhythmic drugs
D. Flecainide, propafenone, and sotalol can be safely used in patients with ischaemic heart
disease, ventricular hypertrophy, or heart failure

 When a patient presents with symptoms of A fib and the diagnosis is confirmed the first step in
management is to see whether he is stable or not: If clinically unstable -->
electrical/pharmacological cardioversion (if presents within 48 hours --if presents after 48 hours
anticoagulate for 3 weeks, then electrical/pharmacological cardioversion). NOTE - you will
NEVER be asked to pick between electrical or pharmacological cardioversion
 Which drugs are 1st line for pharmacological cardioversion in UK? Amiodarone,
flecainide and propafenone (dofetilide and ibutilide are newer agents used in USA, not in
UK - dont pick these as options because they will be wrong!)
 Vernakalant (a drug probably no one has heard of) - another drug that can be used in
pharmacological cardioversion, however, is not available in UK
 HOW TO PICK BETWEEN FLECAINIDE, PROPAFENONE AND AMIODARONE?
EASY - Amiodarone is drug of choice for patients with underlying cardiovascular disease
and the other two are used ONLY if patient has minimal heart disease (i.e. no previous
MIs, heart failure etc)
 If the patient however is STABLE CLINICALLy - Rate control should be the first line
strategy for managing symptoms. Patients should be offered a standard beta blocker (not
sotalol) or rate limiting calcium channel blocker as initial monotherapy to reduce the
heart rate and control the symptoms of AF.
For patients who are sedentary and have non-paroxysmal AF, you could consider digoxin
monotherapy as a first line treatment. If the patient’s symptoms are not controlled on
monotherapy, consider combination therapy with two of the following:
• A beta blocker
• Diltiazem
• Digoxin.
If the patient is still symptomatic on combination therapy --> rhythm control.
 RHYTHM CONTROL - heart problems --> amiodarone; no heart problems -->
flecainide, propafenone or sotalol (they wont ask you to pick between these as this is the
job of a cardiologist)
 what happens is rhythm control fails? “pace and ablate” (insertion of a pacemaker with
AV node ablation) could be considered.
 A is incorrect - often successful if initiated within seven days (preferably 48hours) of
onset of atrial fibrillation.
 B is wrong - Sotalol is commonly used to prevent recurrences of atrial fibrillation
following successful spontaneous or attempted cardioversion. Digoxin is neither a
cardioverting agent nor does it prevent recurrence of atrial fibrillation. Digoxin is a rate
controlling agent
 C - correct - the most dangerous complication of these drugs is QT interval prolongation
and torsades. Patients on these medications must be followed up at regular intervals to
measure the corrected QT interval and the duration of the QRS complex
 D is incorrect as previously discussed - flecainide, propafenone and sotalol are used in
patients with no or minimal heart disease
 "Use with Beta-blockers: Diltiazem can be used in conjunction with beta-blockers to
assist with heart rate reduction. The companion
drug Verapamil should only be used together with a beta-blocker under specialist
guidance." Atrial Fibrillation Association (AFA) UK document pertaining to the use of
rate-limiting CCB. If the first drug fails to control rate a second should be added (again
this is standard approach, it is very possible that a specialist may just switch the patient
directly to rhythm control depending on clinical judgment, but for your exam we follow
the "standard" care which is to add a second rate-control drug. Yes I am aware that
OHCM writes Beta Blockers cant be combined with diltiazem, but that is not true in case
of Atrial Fibrillation. Usually rate will be controlled by bisoprolol or metoprolol or
 diltiazem as monotherapy, but if it happens that it isnt controlled, then add the second
drug (depending on patient preference, etc). Digoxin has very little use in a patient who is
active etc, so the short answer is no. Digoxin is for heart failure and/or sedentary/none-
paroxysmal. Hope that helps

A 67 year old gentleman is brought in by the local ambulance services to the A&E because of
sudden onset of right arm weakness and slurred speech. Neurological examination reveals right-
sided hemiparesis. An urgent CT-scan of the head excludes haemorrhage. Urgent bloods are
ordered and the results are all within normal limits. Which of the following must be started
immediately after ruling out all contraindications?
A. streptokinase
B. urokinase
C. alteplase
D. clopidogrel
E. dipyridamole

 patients who have had an acute ischaemic stroke can be given alteplase (only in specialist
centres due to the risk of bleeding intracerebrally)
 A CT head must first be done (ALWAYS) before initiating alteplase therapy.
 If anyone picks streptokinase (I know for a fact one of the "PLAB academies" says this is first line
in MI and STROKE) you will kill the patient - streptokinase was a drug used YEARS AND YEARS
ago (although used in poorer parts of the world where options are limited) and it was shown to
cause haemorrhagic changes in patients with ischaemic stroke - therefore NEVER PICK THIS
DRUG (urokinase is a crap drug also!)
 alteplase is almost useless after 4.5 hours. It has its maximum benefits within 2 hours. Although
the time frame is not mentioned in the question stem (it may or may not be in the exam) you
can safely assume that a patient being brought in by ambulance with sudden onset, is within the
time frame. And also the GMC would want you to specifically know that the most effective
therapy for acute ischaemic stroke is undoubtedly alteplase (it has a number needed to treat of
4 - which is very very good!)
 Just a quick point on ASPIRIN: aspirin (300mg) is given to every patient with an acute ischaemic
stroke (providing haemorrhagic stroke is completely ruled out). If the patient has dysphagia then
it is given RECTALLY, if not dysphagic then oral aspirin 300mg. 300mg of aspirin is given to the
patient for 2 weeks and then the dose is reduced for long-term maintenance therapy. If patient
has previous history of dyspepsia related to apsirin - ASPIRIN + PPI
 Another critical point about acute ischaemic stroke: ANTICOAGULATION - when is it necessary?
(never routinely used) Antiphospholipid syndrome - induced stroke AND Atrial fibrillation
  What investigations do ALL stroke patients receive? ECHOCARDIOGRAM + ECG + HOLTER (only if
initial ECG is normal) + CAROTID DOPPLER SCAN
 STROKE + CAROTID ARTERY STENOSIS > 70% = CAROTID ENDARTERECTOMY
 If a patient suffers an acute haemorrhagic stroke secondary to anticoagulation e.g warfarin
(elevated INR) - use prothrombin complex concentrate + vitamin K to reverse the coagulopathy

A 72 year old Afro-Caribbean woman presents to her GP with intermittent palpitations that she finds
distressing. They have been occurring for several months but are getting more frequent and she is now
experiencing them every day. She has a body mass index of 32.4 and has hypertension, depression, and
osteoarthritis. Her heart rate is 86 bpm and irregular, her blood pressure is 137/82 mm Hg, and
cardiovascular examination is otherwise normal. AF is confirmed on ECG. What is the most appropriate
initial management option?
A. Discuss starting rate control medication and stroke risk/anticoagulation
B. Discuss stroke risk and anticoagulation
C. Refer to cardiology
D. Discuss starting rate control medication
E. Discuss starting rhythm control medication

 The answer here is A - she does not need assessment by cardiologist if diagnosis of A fib has
been made. This patient will need a discussion about AF that includes information about AF,
stroke awareness and prevention. However, she is symptomatic so the priority needs to be
focused on relieving her symptoms. For most patients, rate control would be the first line
treatment strategy. If rate control fails, then she will need assessment by cardiology etc (but we
will come onto that)
 This patient is stable and has been diagnosed with A fibrillation. Now because her physical
examination was NORMAL she does not require referral for any investigations (e.g. transthoracic
echocardiohgram, TOE). It is enough for the GP to initiate a conversation of rate control (1st line
therapy for A fib in a stable patient) AND at the same appointment MUST take about stroke
prevention with anticoagulation
 If however, the rate control is not working, the next step is to ADD ANOTHER RATE CONTROL
MEDICATION (e.g. Beta Blocker + Calcium channel blocker)
 If this step fails then the patient will be referred to the cardiologist who is the ONLy specialist
who can initiate a patient on rhythm control e.g. flecainide, propafenone, amiodarone