• most common cardica dysrhythmia

• often diagnosed as incidental finding

• prevalence increase with age

• 10% aged ≥ 80yo

• rapid irregular contraction of atria and irregular ventricular response

• main consequences

  • reduced cardiac output

  • formation of thrombus wihtin atria

• 50% revert back to SR within 24hrs

Management

1. confirm the diagnosis

• comprehensive history

  • palpitations

  • tachycardia

  • tiredness

  • weakness

  • dizziness

  • mild SOB

  • reduced exercise tolerance

• precipitating triggers

  • exercise

  • alcohol

  • stress

• examination

  • pulse

  • blood pressure

  • jvp

  • heart sounds

  • lungs

  • peripheral oedema

• associated conditions

  • HTN

  • cardiovascular disease

  • cerebrovascular diseeae

  • DM

  • COPD

  • hyperthyroidism

  • excessive etoh

  • infection

• ECG

• Bloods

  • TSH - exclude hyperthryoidism

  • CBC - anaemia, infection

  • electrolytes

  • Cr/eGFR

  • LFT - prior to anticoagulation

  • glucose/HbA1c

  • INR - if warfarin to start

• ECHO

  • newly diagnosed should be referred for TTE

  • LV function

• Other

  • CXR

    Holter monitor

2. consider if urgent referral to secondary care

• HR >150/min or sBP \<90

• Chest pain

  • Acute ischaemic changes on ECG

• increase sob

• severe dizziness

• loss of conciousness

• any complciations of AF

  • TIA

  • stroke

  • acute ischaemia

  • acute heart failure

• discuss with cardiologist

  • PAF

    • consider amiodarone/sotalol

  • ECG abnormal

    • Wolff-Parkinson-White syndrome

    • prolonged QT syndrome

  • Known or suspected valvular disease

  • Ongoing symptoms despite appropriate rate control treatment

3. Determine type of AF

• Paroxysmal

  • recurrent episodes

  • \<7d

  • Rhythm control = preferred treatment

• Persistent

  • >7d

  • has not spont. resolved

  • treatment rate or rhythm control

• Permanent

  • present for more than 1 yr

  • cardioversion has failed or not attempted

  • rate control = preferred

4. symptom management

• rate or rhythm control

• no significant differnece between rate or rhythm control with respect to rates of stroke and mortality

• rate control

  • majority

  • asymptomatic

  • permanent

  • target

    • ≤ 80/min

    • ≤ 115/min when moderate walking

  • beta blockers

    • not sotalol

  • rate limiting CCB

    • verapamil

    • diltiazem

  • digoxin

    • if moderately active

    • unlikely to achieve rate control with digoxin alone

• rhythm control

  • PAF

  • persistent and ongoing symptoms

  • structural heart disease

    • AF not well tolerated

  • Beta blocks

    • metoprolol

    • atenolol

  • Sotolol

    • beta blcoker with additional class III antiarrythmic activity

  • Flecanide

    • class I anti-arrythmic

  • Amiodarone

    • class III antiarrhythmic

  • Radiofrequency ablation of AF

5. Antithrombotic treatment

• pro thrombotic

• approximately 5 fold increase

• risk is same PAF or sustainted AF

• CHADS2,

  • if >2 - OAC

  • if \<2:

    • CHA2DS2-VASc

      • ≥ 2

        • OAC

      • 1

        • OAC or aspirin

        • anticoagulant preference

      • 0

        • no treatment

• HAS-BLED

  • Hypertension sBP >160

  • abnormal renal and liver function - 1 each

  • Stroke - 1

  • Bleeding

  • labile INR

  • Elderly

  • Drugs or etoh - 1 each

  • maximum = 9