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Atrial Fibrillation
Cardiovascular
Palpitations
Dizziness/syncope
Stroke
Atrial Fibrillation (AF) is a common supraventricular arrhythmia characterized by rapid, irregular atrial activation and an irregular ventricular response. Management involves stroke prevention, rate control, and rhythm control.
🎯 Key Learning Objectives
- Identify AF on ECG (absent P waves, irregularly irregular rhythm).
- Calculate stroke risk using CHA2DS2-VASc score.
- Assess bleeding risk using ORBIT or HAS-BLED scores.
- Implement rate control strategies (Beta-blockers, Diltiazem).
- Determine the need for rhythm control (cardioversion) versus rate control.
- Recognize valvular AF as an absolute indication for Warfarin over DOACs.
🔬 Pathophysiology
Multiple re-entrant circuits within the atria, often triggered by pulmonary vein ectopics, lead to disorganized electrical activity. Loss of atrial contraction causes stasis in the left atrial appendage, increasing thrombus risk.
🩺 Clinical Features
Symptoms
- Palpitations
- Shortness of breath
- Chest pain
- Lightheadedness
- Syncope
Signs
- Irregularly irregular pulse
- Variable intensity of first heart sound
- Pulse deficit (radial vs apical pulse disparity)
🔬 Investigations
🛏️ Bedside
- ECG
- Manual pulse check
🩸 Bloods
- TFTs (common trigger)
- U&Es
- Clotting profile
- Full Blood Count
📷 Imaging
- Echocardiogram (to check for structural/valvular heart disease)
⚗️ Special
- 24-hour Holter monitoring
- Transoesophageal echo (prior to cardioversion)
💊 Management
🚨 Acute Management
- Heparin if high risk
- DC Cardioversion if haemodynamically unstable
- Flecainide or Amiodarone for pharmacological cardioversion
📋 Long-Term
- Anticoagulation (Apixaban, Rivaroxaban, or Warfarin)
- Beta-blocker (first-line rate control)
- Digoxin (sedentary patients)
🏃 Lifestyle
- Alcohol reduction
- Caffeine moderation
- Weight loss
- CPAP for sleep apnoea
⚠️ Complications
Ischaemic stroke
Tachycardia-induced cardiomyopathy
Heart failure
Thromboembolism
⭐ High-Yield Pearls
- A CHA2DS2-VASc score of 2+ in males (1+ in females) requires anticoagulation.
- Rate control is first-line for most except those with reversible cause, new-onset (<48h), or heart failure.
- DOACs are preferred over Warfarin unless the patient has a metallic valve or mitral stenosis.
- Always check TFTs in new-onset AF.
- If AF duration >48h, anticoagulation is required for 3 weeks prior to elective cardioversion.
📖 GUIDELINES:
NICE NG196
ESC AF Guidelines
❓ Practice Questions
Q1. A 62-year-old man presents to the emergency department with 40 minutes of crushing retrosternal chest pain radiating to his left jaw. His ECG shows 3mm ST-segme…
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Q2. A 74-year-old woman with a history of hypertension presents with increasing breathlessness on exertion and ankle swelling. Echocardiogram reveals a left ventric…
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Q3. An 82-year-old man is found to have an irregularly irregular pulse during a routine health check for his Type 2 Diabetes. An ECG confirms atrial fibrillation wi…
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