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“This patient presented on account of chest discomfort. Please examine their cardiovascular system and present your findings to the examiners.”
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- Cardiovascular 0%
Atrial fibrillation is the most common arrhythmia with a prevalence of up to 2% of the population, with a greater preponderance for men, compared to women.
- no distinct p-waves;
- irregular R-R intervals;
- variable atrial cycle duration;
- none (European Heart Rhythm Association score I);
- associated shortness of breath (at rest or on exertion);
- reduced exercise tolerance;
- syncope or pre-syncope;
- symptoms from associated disease (such as heart failure).
European Heart Rhythm Association score II mild symptoms with nor effect upon ADLs (activities of daily living);
European Heart Rhythm Association score III severe symptoms with ADLs affected;
European Heart Rhythm Association score IV disabling symptoms with ADLs unable to be carried out at all.
Atrial fibrillation (AF) is an irregularly irregular heart beat that results from asynchrony between atrial systole and atrioventricular. This results in a reduction of up to 50% of cardiac output as well as an inconsistent stroke volume.
AF can be persistent or paroxysmal (intermittent), and both confer the same risk of stroke (see below). There are five different types of AF based upon the duration of symptoms:
First diagnosed AF – Initial presentation of first episode;
Paroxysmal – Self terminates and usually present for < 48 hours, but can be present for < 7 days;
Persistent > 7 days;
Long standing AF > 1 year;
Permanent > 7 days and no evidence of sinus rhythm.
Causes of AF:
- coronary artery disease;
- heart failure (including cardiomyopathies);
- congenital heart defects (ASD or VSD for example);
- valvular heart disease;
- thyroid dysfunction;
- alcohol excess;
- caffeine excess.
- venous thromboembolism;
- heart failure.
Stasis of the blood in the primarily left atrial appendage leads to the development of thrombi, which leads to cerebrovascular accidents. In patients aged between 80-89, there is a risk of nearly 25% for stroke with AF. Compared to the general population, there is a five times increased risk of stroke with AF.
- full blood count (infection and anaemia);
- biochemsitry (electrolyte disturbance);
- thyroid function tests (hyperthyroidism).
Echocardiogram: determine atrial and ventricular size as well as valvular defects
Coronary angiography if any ventricular dysfunction or ischaemia suspected
Management of AF is dependent upon the following factors:
- duration of onset:
- < 48 hours;
- > 48 hours.
- systemic symptoms:
- associated illnesses (such as sepsis or myocardial infarction);
- cerebral dysfunction.
- underlying cause.
The acute management of AF, in for example a younger patient, when in someone who has had symptoms for less than 48-hours is different to an older patient with longstanding AF or unclear onset of AF with a normal blood pressure and no evidence of decompensation.
Rate control can be via digoxin (in less ambulant patients) and/or beta-adrenergic receptor blockers (such as bisoprolol) in those with a normal blood pressure (above 100 mmHg systolic.
Digoxin results in increased contractility and excitability of the myocardial cells. It decreases the propagation and generation of the sion-atrial and atrioventricular nodes and conducting tissues. It is the latter’s vagal effect which is if primary use in AF, by reducing conduction and thereby reducing the ventricular rate.
Digoxin is primarily really excreted and hence if there is significant renal impairment, the dose has to be reduced (as well as in the elderly; with hypokalaemia/hypomagnesaemia and hypothyroid patients). The normal loading dose is 500 micrograms and then another repeat dose 6 hours later.
- ectopic ventricular beats;
- ventricular tachyarrhythmias;
- supraventricular tachycardias (paroxysmal);
- vomiting and anorexia;
- xanthopsia (yellow vision); photophobia and blurred vision;
If medications are not an option, such as with hypotension (beta-adrenergic receptor blockers cause hypotension) or the patient has decompensation, then amiodarone may be an option, with a loading dose of 300mg intravenously over 1 hour and then 900mg intravenously over the following 23 hours. Or DC (direct current) cardioversion under controlled settings and a general anaesthetic.
Prevention of stroke is a key issue in atrial fibrillation and the most effective method is anti-coagulation. The scoring system to determine if someone should receive anticoagulation is via the CHA2DS2-VASc score:
C Congestive cardiac failure with dysfunction of the left ventricle (mod-severe) 1
H Hypertension 1
A2 Age equal or greater than 75-years 2
D Diabetes mellitus
S2 History of stroke or transient ischaemic attack or thromboembolism 2
V Vascular disease e.g. peripheral vascular disease or history of myocardial infarction 1
A 65-74 years old 1
Sc Female (sex) 1
In patients with a score of either 2 or above, oral anticoagulation should be offered. Up until 2-3 years ago, the only option was the vitamin K antagonist warfarin, however, there are also now Novel Oral Anti-Coagulants (NOACs) now available on the market.
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Question 1 of 7
1. Question1 point(s)Category: Cardiovascular
What is the diagnosis?CorrectIncorrect
Question 2 of 7
2. Question1 point(s)Category: Cardiovascular
Fill in the blanks to show how to calculate a CHA2DS2-VASc score:
- C = [congestive cardiac failure]}
- H =
- A2 = Age >
- D =
- S2 =
- V =
- A = Age to
- Sc = Sex =
Question 3 of 7
3. Question1 point(s)Category: Cardiovascular
Which JVP abnormality is expected in atrial fibrillation?CorrectIncorrect
Question 4 of 7
4. Question1 point(s)Category: Cardiovascular
What does the HAS-BLED mnemonic stand for?
- H =
- A = Abnormal or function
- S =
- B =
- L =
- E = Elderly, age >
- D = or alcohol
Question 5 of 7
5. Question1 point(s)Category: Cardiovascular
By how much does AF increase an individual’s risk of a stroke?
Risk increased by a factor of .
Question 6 of 7
6. Question1 point(s)Category: Cardiovascular
Name three NOACsCorrectIncorrect
Question 7 of 7
7. Question1 point(s)Category: Cardiovascular
What stroke prophylaxis should be offered to a patient with a CHA2DS2-VASc score of only 2?CorrectIncorrect