CARDIOLOGY

Atrial Fibrillation
Atrial fibrillation (AF) is a Supra ventricular tachyarrhythmia resulting from irregular disorganized
electrical activity and ineffective contraction of the atria.

AF is classified according to the pattern of episodes;

 Paroxysmal AF - episodes lasting longer than 30 seconds but less than 7 days (often less than 48
hours) that are self-terminating and recurrent.
 Persistent AF - episodes lasting longer than 7 days (spontaneous termination of arrhythmia is
unlikely to occur after this time) or less than 7 days but requiring pharmacological or electrical
cardioversion.
 Permanent AF - AF that fails to terminate using cardioversion, AF that is terminated but relapses
within 24 hours, or long-standing AF (usually longer than 1 year) in which cardio version has not
been indicated or attempted (sometimes called accepted permanent AF).

Pathophysiology
AF is associated with electrophysical and /or structural abnormalities of the artia. The autonomic
nervous system may also play a role in some cases. The triggers of AF are rapidly firing foci, most
commonly with the pulmonary veins. These triggers cause propergating wavelets, which may lead to re-
entrrant circuits in abnormal atrial myocardium. When the atrioventricular node receives more electrical
impulses than it can conduct, an irregular ventricular rhythm result. The ventricular rate of untreated AF
often avenges between 160 - 180 beats per minutes, although this is typically slower in older people.
Sustained AF results from structural remodeling of atrial tissue (most notably fibrosis).

Causes
AF is most commonly associated with hypertension, coronary artery disease, and myocardial infarction.
Other etiologies include;

 Cardiac or valve conditions, such as;

o Congestive heart failure
o Rheumatic value disease
o Atrial or ventricular dilatation or hypertrophy
o Pre excitation syndromes (such as Wolf- Parkinson-White syndrome)
o Sick sinus syndrome
o Congenital heart disease
o Inflammatory or infiltrative disease (such as pericarditis, amyloidosis, myocarditis)
 Non cardiac conditions, such as:
o Acute infection
 o Autonomic neural dysfunction (such as vagally induced AF)
o Electrolyte depletion (such as hypokalemia and hyponatremia)
o Cancer (such as primary lung cancer involving the plural and pericardium, and cancers
such as breast cancer and malignant Melanoma metastasizing to the pericardium)
o Pulmonary embolism
o Thyrotoxicosis
o Diabetes mellitus
 Dietary and Lifestyle factors, such as:
o Excessive Caffeine intake
o Alcohol abuse
o Obesity
o Smoking
o Medication exposure (such as thyroxine or bronchodilators)

Complications
The risk from paroxysmal AF is thought to be similar to those from persistent or permanent AF,

 Stroke and thrombophism are the main complications of AF. anticoagulation treatment reduces
the risk of stroke by about two thirds.
 Heart failure can occur because the disorganized electrical conduction in the Atria results in
ineffective ventricular filling. The cardiac output can be reduced by as much as 10 - 20%, pushing
an already compromised ventricle into failure.
 Tachycardia induced cardiomyopathy and critical cardiac ischemia may results from the
persistently elevated ventricular rate seen in uncontrolled AF.
 The mortality rate of people with AF appears to be correlated with the presence and severity of
concomitant cardiovascular disease.

Diagnosis
Suspected AF in people with an irregular pulse, with or without any of the following:

 Breathlessness
 Palpitations
 Chest discomfort
 Syncope or dizziness
 Reduced exercise tolerance, malaise /listlessness, decrease in mentation. or polyuria
 A potential complication of AF, such a stroke, transient ischemic attack, or heart failure

To confirm a diagnosis of AF, arrange and electrocardiogram

 If AF is present, the ECG will have no P waves, a chaotic baseline, and then irregular ventricular
rate.
  The ventricular rate is often 160 - 180 beats per minute but can be lower, especially in people
who are asymptomatic.
 The ventricular complexes look normal unless there is a ventricular conduction defect

If paroxysmal AF is suspected and AF is not detected on standard electrocardiography, arrange

ambulatory electrocardiography:

 A 24 hr - ambulatory ECG monitor is normally used in people with suspected asymptomatic

episodes of paroxysmal AF or symptomatic episodes that are less than 24 hours apart.
 An event recorder ECG is normally used in people who have symptomatic episodes more than
24 hours apart. In some centres, a 7-day Holter monitor is used as an alternative to and event
recorder, especially when asymptomatic paroxysms of AF are suspected.

Differential diagnosis
The differential diagnosis of an irregular pulse include:

 Atrial flutter - characterized by a saw-tooth pattern of regular atrial activation on the ECG.
 Airtel extrasystoles - common and may cause and irregular pulse
 Ventricular ectopic beats
 Sinus tachycardia - sinus Rhythm with more than 100 beats per minute
 Supra ventricular tachycardias, including atrial tachycardia, atrioventricular nodal re-entry
tachycardia, and Wolf-Parkinson-White syndrome
 Multifocal atrial tachycardia - often seen in people with sever pulmonary disease
 Sinus Rhythm with premature contraction

Management
For people presenting acutely with AF:

 Carry out emergency electrical cardioversion, without delaying to achieve anticoagulation, in

people with life threatening hemodynamic instability caused by new onset atrial fibrillation.
 In people with a real fibrillation presenting acutely without life threatening hemodynamic
instability, offer rate or rhythm control if the onset of the arrhythmia is less than 48 hours, and
start rate control if it is more than 48 hours of is uncertain.
 Consider either pharmacological or electrical cardioversion depending on clinical circumstances
and resources in people with new onset atrial fibrillation who will be treated with a rhythm
control strategy
 If pharmacological cardioversion has been agreed on clinical and resource grounds for new on
set atrial fibrillation, offer:
o A choice of flecainide or amiodarone to people with no evidence of structural or
ischemes heart disease
o Amiodarone to people with evidence of structural heart disease

For people presenting with AF:

  Assess for signs and symptoms and arrange tests to confirm or rule out underlying causes of AF,
including:
o Cardiac causes, such as hypertension, valvular heart disease, heart failure, and
ischaemic heart disease - review of the electrocardiogram may identify and old
myocardial infarction; arrange a trans thoracic echocardiogram if there is high risk or
suspicion of underlying structural heart disease (such as heart murmur) or functional
heart disease (such as heart failure) that will influence subsequent management (for
example choice of antiarrhythmic drugs).
o Respiratory causes, such as chest infection or lung cancer- arrange a chest X-ray if lung
pathology is suspected.
o Systemic causes such as excessive alcohol intake, hyperthyroidism, electrolyte
depletion, infection, Diabetes mellitus - use clinical judgement to determine the need
for thyroid function test, full blood count, and/or blood urea and electrolytes, Calcium,
magnesium and glucose measurements.

Anticoagulation

 Assess the person's stroke risk using the CHA2DS2VASc assessment tool.
 Anticoagulation treatment is generally indicated by CHA2DS2VASc scores of 2 or more, and
treatment should also be considered for males with the score of one or more (taking bleeding
risk into account)
 Where anticoagulation is being considered, use the ORBIT bleeding risk score to assist the risk of
a major bleed. (N.B. use the ORBIT bleeding risk score because, evidence shows that it has a
higher accuracy in predicting absolute bleeding risk than other bleeding risk tools. Although
ORBIT is the best tool for this purpose, other bleeding risk tools may need to be used until it is
embaded in clinical pathways and electronic systems).
 Offer monitoring and support to modify risk factors for bleeding including uncontrolled
hypertension, harmful alcohol consumption, and concurrent use of medication including
antiplatelet, selective serotonin reuptake inhibitor (SSRIs) and non- steroidal anti-inflammatory
drugs (NSAIDs).
 Anticoagulation can be achieved with drugs apixaban, dabigatran etexilate, reveroxiban, or a
vitamine K antogonist depending on the person's clinical features and preferences.
 Rate control
o Offer rate control as the first line strategy to people with atrial fibrillation, except in
people
 Whose atrial fibrillation has a reversible cause
 Who have heart failure thought to be primarily caused by atrial fibrillation
 With new onset atrial fibrillation (<48 hours of onset)
 For whom a rhythm control strategy would be more suitable based on clinical
judgement
o Standard Beta blocker (that is a Beta blocker other than sotalol) e.g.: metoprolol or a
rate limiting Calcium channel blocker ego: diltiazem is recommended as first line
treatment for most people with AF. The choice of drug should be based on the person's
 symptoms, heart rate, comorbidities and preferences. Digoxin is a possible alternative
only in people with non-paroxysmal atrial fibrillation who are sedentary (do not or very
little physical exercise)
 Rhythm control:
o Rhythm control (electrical of pharmacological is appropriate) for people:
 Whose AF has a reversible cause
 Who have heart failure thought to be primarily caused, or worsened by AF.
 For whom a rhythm control strategi would be more suitable based on clinical
judgement
 Whose symptoms continue after heart rate has been controlled or for whom a
rate-control strategy has not been successful.
o People having cardioversion for atrial fibrillation that has persisted for longer than 48
hours, offer electrical (rather than pharmacological) cardioversion. Consider amiodarone
therapy starting 4 weeks before and continuing for up to 12 months after electrical
cardioversion to maintain sinus rhythm.
o A drug treatment for long term rhythm control is needed, consider a standard Beta
blocker (that is, a Beta blocker other than sotalol) as first line treatment unless there are
contraindications. If beta blockers are contraindicated or unsuccessful, assess the
suitability of alternative drugs for rhythm control, taking comorbidities in into account.
o In paper with atrial fibrillation in whom the duration of arrhythmia is greater than 48
hours or uncertain and considered for long term rhythm control, delay cardioversion
until they have been maintained on the therapeutic anticoagulation for a minimum of
three weeks. During this period offer rate control as appropriate.
 Ablation strategies:
 If drug treatment has failed to control symptoms of atrial fibrillation or is unsuitable:
o Offer left atrial catheter ablation to people with paroxysmal atrial fibrillation c
o Considered left atrial catheter or surgical ablation for people with persistent atrial
fibrillation
 Considering pacing and atrioventricular node ablation for people with permanent atrial
fibrillation with symptoms or left ventricular dysfunction thought to be caused by high
ventricular rates.

Scoring tool
The CHA2DS2VASc score tool is used to assess person stroke risk. Adding together the points allocated
to each risk factor gives a total CHA2DS2VASc score which guides the decision to offer antithrombotic
treatment:

 Congestive heart failure/left ventricular dysfunction (heart failure with reduced ejection
fraction, or people with recent decomposition heart failure requiring hospitalization,
irrespective of ejection fraction) = 1
  Hypertension (define as a resting blood pressure greater than 140 mmHg systolic and / or
greater than 90 mmHg diastolic on at least two occasions or current anti-hypertensive
Pharmacology treatment = 1
 Age order than or equal to 75 years =2
 Diabetes mellitus (defined as fasting plasma glucose levels of 7 mmol/l or more or treatment
with oral hypoglycemic drugs and/or insulin = 1
 Stroke/TIA = 2
 Vascular disease (prior myocardial infarction, peripheral arterial disease, or aortic plaque) = 1
 Age 65 - 74 years =1
 Sex category (female) = 1

ORBIT tool

The ORBIT tool is used in adult patients with atrial fibrillation, to assess risk of major bleeding with
anticoagulation. (N. B. Use the ORBIT bleeding risk score because evidence shows that it has a higher
accuracy in predicting absolute bleeding risk than other bleeding risk tools. Although ORBIT is the best
tool for this purpose, other bleeding risk tools for this purpose, other bleeding risk tools may need to be
used until it is embedded in clinical pathways and electric systems)

 Male: Haemoglobin <13 g/dl or haematocrit < 40% (+2)

 Females: Hemoglobin <12 g/dl or haematocrit <36% (+2)
 Age >74 years (+1)
 Bleeding history (any history of GI bleeding, intracranial bleeding, or heamorrhagic stroke) (+2)
 GFR <60% ml/min/1.73m2 (+1)
 Treatment with antiplatelet agents (+1)