Atrial Fibrillation

Types

• Paroxysmal - episodes of < 7 days

• Persistent - > 7 days

• Longstanding > 1 year

• Permanent - when SR is no longer being pursued

Info

• 2 to 4% prevalence

• Independent risk of stroke, heart failure, all-cause death

History

Symptoms

• SOB

• Chest pain

• Hypotension

• Palpitations

• Can be episodic

Determine

• If new or longer

• If constant or paroxysmal

Causes

• Hypertensive heart disease

• IHD

• Heart failure

• Valvular heart disease

• Cardiomyopathy

• Alcohol or caffeine

• Thyrotoxicosis

• Respiratory COPD OSA PE CAP

• Surgery

• Infections

• Obesity

Stroke Risk Factors

• Age > 65

• Heart failure

• HTN

• Diabetes

• History of TIA

• Female

• Vascular disease

Exam

• Full CV exam

Investigations

• Confirm on ECG

• Echo

• Bloods

  • FBC, UEC, LFT, TFT, INR, APTT, Iron

Refer

• Emergency if

  • Red flags or persistent severe symptoms

  • AF for less than 48 hours suitable for urgent rhythm control and cardioversion

• Urgent cardiology assessment if

  • Symptomatic AF for > 7 days

  • Resting HR > 110 bpm

  • Signs of symptoms of heart failure

• Non-Urgent cardiology for most other patients with new AF or if any clinical concerns

Management

• Treat any underlying causes + Comorbidities

• Start anticoagulation if indicated

  • CHADVASC > 2 for men and > 3 for women

• If haemodynamically stable and resting HR > 100 BPM start rate control therapy

  • Aim < 110 BPM

  • If no known LV systolic dysfunction or heart failure

    • B-Blocker

      • e.g. Metoprolol 25mg MR

    • Non-dihydropyridine Ca2+ Blocker

      • Diltiazem 180mg daily

  • If LV systolic dysfunction of heart failure

    • B-Blocker

• If suboptimal control, add Digoxin