Atrial Fibrillation

Daniel Jones
rapidly firing foci
bombard the AV node with many signals
 Epidemiology
most common sustained cardiac
arrhythmia

incidence ↑ with age and female sex

25% lifetime risk over the age of 40

New onset AF in 10% of AMI and

20% HF (worse prognosis)
 Classification
Paroxysmal- Self
terminating within 7 days
and intermittent

Persistent - fails to self-

terminate and requires
intervention

Longstanding Persistent -
>12 months

Permanent
 Risk Factors
Age Pulmonary Emboli

Diabetes Hyperthyroidism

Hypertension Valvular Disease

(Mitral ++)
Coronary Artery Disease
cardiac and
Congestive Heart failure thoracic surgery

Alcohol Obesity
 History
Asymptomatic

Palpitations - racing or
galloping

SOB

chest pain

Dizziness

Dyspnoea
 Exam

Rapid or irregular pulse

rate

Blood Pressure

elevated JVP

Added heart sounds

 ECG
Absent P waves, presence of fibrillary waves that
vary in size, shape and timing, Irregularly irregular
 Echocardiogram
LVH

Left atrial enlargement

valvular disease

cardiomyopathy with
low LVEF

left atrial appendage

thrombus
 Cardiac Testing

24-48 hour holter

monitoring

stress testing
 Laboratory Testing
Cardiac enzymes - Ischaemia ?
cause or consequence

↓TSH and ↑free T4

FBC/electrolytes - high or low K, low
Mg

DM
 Chads2
CHA2DS2-VASc score includes sex, VTE and
vascular disease history
 Management
Diagnosis of AF

Assessment of duration

Assessment of anticoagulation

Rate or Rhythm control

Treatment of underlying/associated
disease
 New-onset AF
CHA2DS2-VASc 0-1/stable/no thrombus

most revert back to sinus rhythm spontaneously

within 24 hours

rate control with Beta Blocker/CCB

Anticoagulation

electrical cardioversion OR

Pharmacological cardioversion (Flecainide,

amiodarone)
 CARDIOVERSION
AF < 24-48 hrs,
cardiovert without
anticoagulation

AF > 24-48 hrs

anticoagulant for 3-4
weeks prior and 4
weeks after due to risk
of unstable into-atrial
thrombus
 DOACS
Compared with dose‐adjusted
warfarin, in adults with AF eligible for
long‐term anticoagulation with a
vitamin K agonist, factor Xa inhibitors
seem to be beneficial in terms of
reducing mortality and the incidence
of stroke, and most factor Xa
inhibitors appear to be less commonly
associated with bleeding events.
 Clinical Decisions
CCB’s preferred over B-Blockers in Chronic Lung Disease
(bronchospasm)

Can combine these if mono therapy inadequate

CHA2DS2-VASc 0-1 can cardiovert without anticoagulation

Flecainide contraindicated in CAD

Digoxin or amiodarone preferred for control in HF

Heparin & Warfarin until INR =2-3

DOAC’s for anticoagulation if non-valvular AF

NO Dabigatran if Renal insufficiency

Ongoing Management
Risk factor management

first episode new-onset AF do not continue

on rhythm maintenance after cardioversion

Aspirin

long term anticoagulation in high risk

patients

Regular long term follow-up (echo, ECG,

stress testing)
Thank you