Paroxysmal: Self-terminating, duration <7 days (usually <48 hours)
Persistent: >7 days, requires intervention to restore sinus rhythm
Chronic: Persistent AF where restoration to sinus rhythm is not attempted
Valvular: Associated with moderate-severe mitral stenosis or mechanical heart valves

Investigations

Baseline bloods: FBC, UEC, TFT
Urine MCS and CXR: To identify infection or contributing pathology
ECG: Confirms diagnosis; evaluate for ischaemia, LVH, or valvular disease
Echocardiogram: Assess for mural thrombus, atrial/ventricular size, and valvular function
LFTs: Consider for alcohol-related AF or medication monitoring

Catheter Ablation: Indications and Considerations for Referral

Indications:

Symptomatic AF refractory to medical therapy
Paroxysmal AF uncontrolled with antiarrhythmic drugs
Younger patients with minimal comorbidities

Considerations:

Requires specialist cardiology referral
Success higher in paroxysmal AF than persistent or chronic AF
Risks include cardiac tamponade, pulmonary vein stenosis, thromboembolism

Additional Notes

HAS-BLED Score: Assess bleeding risk prior to initiating anticoagulation

Criteria for Rhythm Control

Most cases of AF focus on rate control, except in the following situations:

Symptomatic AF (e.g., palpitations, dizziness, dyspnoea)
Patient is physically active
Ventricular dysfunction (e.g., LVEF <40%)
First presentation within <48 hours
Difficulty attaining rate control with medications
Haemodynamic instability: Requires electrical cardioversion (100J biphasic, 200J monophasic)

Note: Pharmacological cardioversion with IV flecainide or amiodarone can be attempted if the patient is haemodynamically stable

CHA2DS2-VASc Scoring Criteria

Used to assess stroke risk and guide anticoagulation:

C: CHF ≤40% = 1
H: HTN = 1
A: ≥75 years = 2
D: Diabetes = 1
S2: Stroke/TIA/thromboembolism = 2
V: Vascular disease (e.g., MI, PAD) = 1
A: 65–74 years = 1
Sex: Female = 1(if other risk factors present)

Scoring:

If score ≥2 (men) or ≥3 (women), initiate anticoagulation. For males with a score of 1 and females with a score of 2, anticoagulation is considered.

Anticoagulation Pharm Management

First-Line Direct Oral Anticoagulants (DOACs):

Apixaban:
- 5mg BD (reduce to 2.5mg BD if ≥80 years, weight ≤60kg, or Cr ≥133µmol/L)
- For VTE, initial dose is 10mg BD for 1/52, then 5mg BD
Rivaroxaban:
- 20mg OD(15mg OD if CrCl 30–49mL/min)
- For VTE, initial dose is 15mg BD for 3/52, then 20mg OD
Dabigatran
- 150mg BD (reduce to 110mg BD if ≥75 years, CrCl 30–49mL/min, or high bleeding risk)

Warfarin use: Recommended for patients with rheumatic mitral stenosis, mechanical heart valves, or severe kidney impairment; Target INR 2–3

Special Considerations:

If AF detected asymptomatically and onset is unclear:
- Pre-Cardioversion: ≥3 weeks anticoagulation unless TOE excludes thrombus
- Post-Cardioversion: Continue for ≥4 weeks.

Criteria for Hospitalisation

Hypotension
RVR (HR >110)
Significant symptoms: Chest pain, presyncope, syncope

Pharmacological Management

Rate Control:

BBs: Metoprolol 25–100mg BD, atenolol 25–100mg OD

Calcium channel blockers (if BBs not tolerated): Verapamil, diltiazem (180–360mg OD)

Digoxin: Add-on in sedentary patients or if rate control is insufficient
Amiodarone: Reserved for refractory cases

Rhythm Control:

Flecainide: For structurally normal hearts
Amiodarone/Sotalol: If structural or significant heart disease present

Note: Rate control is not required if HR <100 and asymptomatic

Non-Pharmacological Management

Avoid triggers (e.g., caffeine, stress)
Optimise risk factors (e.g., manage HTN, OSA)
Smoking and alcohol cessation
Regular aerobic exercise (e.g., 150min/week)
Maintain healthy BMI <25

Notes:

Use dihydropyridine CCBs + flecainide cautiously in patients with LV dysfunction or HF
Atrial flutter follows similar management, but cardioversion is more effective compared to AF

Atrial Fibrillation (AF)

Aetiology:

Structural/electrical abnormalities, such as coronary artery disease (CAD), heart failure (HF), hypertension (HTN), and valvular heart disease.
Metabolic causes: Hyperthyroidism, alcohol (ethanol) use.
Reactive causes: Infections, sepsis, pulmonary embolism (PE).

Risk Factors:

Cardiovascular risk factors: obesity, diabetes, smoking, OSA.
Older age, male sex.
Triggers: psychological stress, caffeine, dehydration
Rheumatic mitral stenosis or mechanical heart valve elevates risk.

Triggers:

Stress, infections, caffeine, dehydration, alcohol.

Classifications:

Paroxysmal AF: Self-terminating episodes lasting less than 7 days, often within 48 hours.
Persistent AF: Lasts longer than 7 days and may require intervention.
Long-Standing Persistent AF: Continuous AF lasting for more than 1 year, with rhythm control attempts.
Permanent AF: Rhythm control is not pursued or is unsuccessful.

All types of AF present a similar risk of thromboembolism and stroke.

Conditions That Increase the Risk of AF:

HTN
Diabetes
Obesity
OSA
HF
Thyrotoxicosis
VHD (esp. rheumatic mitral stenosis)
Alcohol use
Acute events (i.e., sepsis, pneumonia, surgery)

Screening:

Annual ECG for those >65; check if pulse is irregular.
Diagnostic workup: FBE, UEC, TFTs, CMP, TTE.
Use the PIRATES mnemonic for new-onset AF causes:
- Pulmonary (i.e., pHTN, PE, COPD, OSA)
- Ischemic (MI)
- Rheumatic heart disease
- Alcohol, arrhythmias (i.e., WPW)
- Thyrotoxicosis, toxins (i.e., adenosine)
- Electrolytes (i.e., hypokalaemia)
- Sepsis, surgery

Investigations:

Labs: FBE, UEC, TFTs, LFTs if alcohol-related.
MCS and CXR.
ECG, Echo for thrombus, valvular issues, atrial/ventricular assessment.
Others: HbA1c, TTE (for VHD, ejection fraction).

Scoring and Anticoagulation:

CHADSVa Score: Determines stroke risk in AF:
- CHF – 1
- HTN – 1
- Age 65-74 – 1, ≥75 – 2
- Diabetes – 1
- Stroke/TIA – 2
- Vascular disease – 1
- Female – 1 (if other risks present)
HAS-BLED Score: Evaluates bleeding risk to balance with anticoagulation therapy.

Anticoagulate at least 3 weeks pre-cardioversion if AF onset unclear.

Management:

Treat the Underlying Cause: Address conditions that increase AF risk, including hypertension, diabetes, obesity, and alcohol consumption.

Anticoagulation Therapy: Required for stroke prevention in AF patients, especially those with risk factors as per CHADSVa and CHA₂DS₂VASc scoring.

Non-Valvular AF: Preferably managed with a NOAC (e.g., Apixaban or Rivaroxaban).
Valvular AF (moderate to severe mitral stenosis or mechanical heart valves): Requires warfarin regardless of other risk factors.

Address Underlying Causes: Manage factors raising AF risk (i.e., HTN, diabetes, obesity, alcohol).

Anticoagulation: Prevents stroke in AF, following CHADSVa score.

Non-Valvular AF: Use NOAC (i.e., Apixaban, Rivaroxaban).
Valvular AF (rheumatic mitral stenosis, mechanical valves): Warfarin preferred.

Dosing for NOACs based on renal function and bleeding risk:

NOAC Dosing	Criteria
Apixaban 5 mg BID	Standard dose
Apixaban 2.5 mg BID	≥2 risk factors (i.e., age ≥80, weight ≤60 kg)
Rivaroxaban 20 mg daily	CrCl ≥50
Rivaroxaban 15 mg daily	CrCl 30–49

Rate Control: Aim for a resting heart rate of less than 110 bpm.

First-Line: Beta-blockers (e.g., Atenolol 25–100 mg or Metoprolol 25–100 mg).
Second-Line: Calcium channel blockers like Diltiazem or Verapamil for patients who cannot tolerate beta-blockers.
Alternative Options: Digoxin or Amiodarone if beta-blockers or CCBs are ineffective or contraindicated.

Rhythm Control (if indicated):

Acute Rhythm Control: Direct current (DC) cardioversion or pharmacological agents (e.g., Flecainide, Amiodarone) for haemodynamically unstable patients.
Long-Term Rhythm Control: Consider for symptomatic patients or those who prefer it; options include Flecainide, Sotalol, or Amiodarone.
Note: Pill-in-the-pocket approach may be used for infrequent symptomatic episodes.

Non-Pharmacological Management:

Lifestyle modifications, including smoking cessation, limiting alcohol intake, maintaining a BMI <27, and regular aerobic exercise (at least 150 minutes per week).
Optimising control of underlying cardiovascular risk factors.

Criteria for Hospitalisation:

Indicator	Description
Hypotension	Low blood pressure
RVR >110 bpm	Rapid ventricular rate
Severe symptoms	i.e., chest pain, syncope

Complications:

Increased risk of thromboembolism, stroke, heart failure, and quality of life impairment.

Notes:

Rate Control vs Rhythm Control: Rate control is generally preferred, except in symptomatic or physically active patients, or those with LV dysfunction.
Acute Management Considerations:
- Haemodynamic stability and duration of AF episode (< or >48 hour) guide the decision for immediate cardioversion.
- Cardioversion should be deferred if left atrial thrombus presence is suspected unless the patient has been on therapeutic anticoagulation for at least 3 weeks.
Anticoagulant Choice in Special Populations:
- Use warfarin over NOACs in patients with valvular AF (rheumatic mitral stenosis, mechanical heart valves) or severe kidney disease.
- Antiplatelet therapy is generally not recommended for stroke prevention in AF.
Additional Recommendations (Heart Foundation 2018):
- Intensive risk factor management for weight, exercise, and sleep apnoea is recommended to reduce AF burden.
- Regular screening for sleep apnoea and adherence to Continuous Positive Airway Pressure (CPAP) if diagnosed

Bookmark Failed!

Bookmark Saved!

Refresh