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Cardiology
Atrial Fibrillation
What is an arrhythmia? what is the pneumonic?
Abnormal rate and/or rhythm
ARRhythmia = A(abnormal) R(rate) & R(rhythm)
What is it AF?
The heart beats abnormally fast
How is this detected?
ECG
What are the symptoms of arrhythmia? & memory trick?
SOB
Abnormally fast, slow or irregular pulse
Dizziness or feeling faint
Palpitations
Pneumonic = S.A.D Palpiations
What are the causes of arrhythmia?
Heart conditions
CHD (can cause angina & MI)
Cardiomyopathy (diseases of the heart muscle - walls of heart chambers
have become stretched, thickened or stiff - makes it harder for the heart to
pump blood to the rest of the body - can lead to HF)
HTN
Ageing
Congenital abnormalities in the electrical pathways
Cardiology 1
, Annually they should be reviewed for what?
Risk of stroke & thromboembolism
Needs to be balanced with the risk of bleeding
Acute Presentation - what is the treatment? when is rate control preferred?
1) Life threatening haemodynamic instability = caused by new onset AF =
emergency electrical cardioversion
2) Not life threatening haemodynamic instability = rate/rhythm control is
offered if onset is <48h
Rate control = onset >48 hours or uncertain
Pharmacological cardioversion involves what?
IV amiodarone/flecainide (to patients with NO evidence of structural or
ischaemic heart disease)
GIVE amiodarone to patients with evidence of structural heart disease
Urgent control then IV BB or verapamil can be given
What is paroxysmal AF?
AF that stops within 7 days - usually within 48h - without any treatment
Treatment
What is the aim of treatment?
Reduce symptoms
Prevent complications (stroke)
Anticoagulation for AF?
IV heparin first without assessment for acute who are receiving no AC until
assessment is made
Then DOAC = first line
Rate control is the first line treatment for AF unless what?
1. New-onset AF
2. AF with a reversible cause
3. AF that would be better treated with ablation strategy
Cardiology 2
, 4. Heart Failure primarily caused by AF
5. Rhythm control would be a better first line option
First line treatment?
RATE control
BB (no sotalol)
OR rate limiting CCB = diltiazem/verapamil
When is digoxin recommended?
AF at rest
Sedentary (does no or very little physical excercise)
NON-paroxysmal AF
AF accompanied by CHF
Monotherapy not effective? if still not effective?
Any of the following two:
BB, diltiazem or digoxin (memory trick = BB DD)
If they don’t work then consider rhythm control
What is the pneumonic?
DIVED BETA
Diltiazem
Verapamil
Digoxin
Beta blockers
When can digoxin & BB be recommended?
When there is no ventricular function
What is Torsade De Pointes? What are the causes? How is it treated?
Type of arrhythmia = heart beat very irregular, usually very fast = not
enough O pumped around the body = brain starved = fainting or even
death
Causes (SSS DHB)
Cardiology 3
, Stress
Strenuous exercise
Sudden noise (alarm etc)
Drugs (Sotalol)
Hypokalaemia
Bradycardia
Treatment
IV Mg sulphate
What are some examples of drugs that cause QT interval prolongation?
A - AntiArrhythmics (Amiodarone, Sotalol, Flecainide)
B - AntiBiotics (Quinolones, Macrolides, Amino-glycosides)
C - AntipsyChotics - (Haloperidol, Quetiapine, Risperidone)
D - AntiDepressants - (SSRIs, TCA)
D - Diuretics
E - AntiEmetics (Ondansetron)
Rhythm control - what is the treatment? (post cardioversion) (memory trick)
Flecainide (avoid in heart disease)
Amiodarone
Beta blocker = FIRST LINE
Propafenone (avoid in heart disease)
Dronedarone (avoid in heart disease)
Sotalol (not as first line)
Pneumonic = FAB rhythms PD
Cardioversion - what are the types? what does it do? what drugs are
recommended?
Pharmacological or electrical
Cardioversion = restores sinus rhythm
Cardiology 4
, For pts with new onset AF - treated with a rhythm control strategy
Flecainide (NOT with for pts with IHD or structural heart problems)
Amiodarone (if structural or IHD)
When do you give electrical cardioversion?
If AF >48h = electrical preferred over pharmacological
But delay until pt has been given fully AC for at least 3 weeks = due to risk
of stroke with EC
Not possible = Heparin immediately before cardioversion
Oral AC (DOAC 1st) = given after cardioversion & continued for at least 4
weeks
Amiadarone in electrical cardioversion?
4 weeks before
Continue for up to 12 months after electrical cardioversion = maintain sinus
rhythm
NOT RECOMMENDED LONG TERM FOR RATE CONTROL
Stroke & Bleeding Risk Calculators
What assessment tool is used to assess stroke & bleeding risk?
CHA2DS2 VASC - stroke
ORBIT= bleeding
What are the risk factors involved in the STROKE assessment?
CHA₂DS₂-VASc
CHF = 1
HTN = 1
Age ≥75 = 2
DM = 1
Stroke/TIA/PE/DVT = 2
Vascular disease (previous MI/arterial disease/aortic plaque) = 1
Cardiology 5
, Age = 65-74 = 1
Sex Female = 1
What risk factors are involved in both BLEEDING assessments? (dropdown)
ORBIT
What is the interpretation of this?
0-2 = low risk
3 = medium risk
4-7 = high risk
Older than 74 = 1
Reduced Hb = 2
Bleeding history (GI bleed, intracranial bleed or haemorrhage
stroke) = 2
Inadequate renal function (GFR <60) = 1
Treatment with anti platelet = 1
Max score = 7
HASBLED
What is the interpretation of results?
0-2 = low risk of bleeding
≥ 3 high risk
HTN = >160mmHg systolic
HTN = 1
Abnormal renal/liver function = 1 or 2
Stroke = 1
Bleeding tendency = 1
Labile INR = 1
Elderly/Age (>65) = 1
Drugs (concomitant aspirin, NSAID or alcohol etc) = 1 or 2
Max score = 9
Cardiology 6
Cardiology
Atrial Fibrillation
What is an arrhythmia? what is the pneumonic?
Abnormal rate and/or rhythm
ARRhythmia = A(abnormal) R(rate) & R(rhythm)
What is it AF?
The heart beats abnormally fast
How is this detected?
ECG
What are the symptoms of arrhythmia? & memory trick?
SOB
Abnormally fast, slow or irregular pulse
Dizziness or feeling faint
Palpitations
Pneumonic = S.A.D Palpiations
What are the causes of arrhythmia?
Heart conditions
CHD (can cause angina & MI)
Cardiomyopathy (diseases of the heart muscle - walls of heart chambers
have become stretched, thickened or stiff - makes it harder for the heart to
pump blood to the rest of the body - can lead to HF)
HTN
Ageing
Congenital abnormalities in the electrical pathways
Cardiology 1
, Annually they should be reviewed for what?
Risk of stroke & thromboembolism
Needs to be balanced with the risk of bleeding
Acute Presentation - what is the treatment? when is rate control preferred?
1) Life threatening haemodynamic instability = caused by new onset AF =
emergency electrical cardioversion
2) Not life threatening haemodynamic instability = rate/rhythm control is
offered if onset is <48h
Rate control = onset >48 hours or uncertain
Pharmacological cardioversion involves what?
IV amiodarone/flecainide (to patients with NO evidence of structural or
ischaemic heart disease)
GIVE amiodarone to patients with evidence of structural heart disease
Urgent control then IV BB or verapamil can be given
What is paroxysmal AF?
AF that stops within 7 days - usually within 48h - without any treatment
Treatment
What is the aim of treatment?
Reduce symptoms
Prevent complications (stroke)
Anticoagulation for AF?
IV heparin first without assessment for acute who are receiving no AC until
assessment is made
Then DOAC = first line
Rate control is the first line treatment for AF unless what?
1. New-onset AF
2. AF with a reversible cause
3. AF that would be better treated with ablation strategy
Cardiology 2
, 4. Heart Failure primarily caused by AF
5. Rhythm control would be a better first line option
First line treatment?
RATE control
BB (no sotalol)
OR rate limiting CCB = diltiazem/verapamil
When is digoxin recommended?
AF at rest
Sedentary (does no or very little physical excercise)
NON-paroxysmal AF
AF accompanied by CHF
Monotherapy not effective? if still not effective?
Any of the following two:
BB, diltiazem or digoxin (memory trick = BB DD)
If they don’t work then consider rhythm control
What is the pneumonic?
DIVED BETA
Diltiazem
Verapamil
Digoxin
Beta blockers
When can digoxin & BB be recommended?
When there is no ventricular function
What is Torsade De Pointes? What are the causes? How is it treated?
Type of arrhythmia = heart beat very irregular, usually very fast = not
enough O pumped around the body = brain starved = fainting or even
death
Causes (SSS DHB)
Cardiology 3
, Stress
Strenuous exercise
Sudden noise (alarm etc)
Drugs (Sotalol)
Hypokalaemia
Bradycardia
Treatment
IV Mg sulphate
What are some examples of drugs that cause QT interval prolongation?
A - AntiArrhythmics (Amiodarone, Sotalol, Flecainide)
B - AntiBiotics (Quinolones, Macrolides, Amino-glycosides)
C - AntipsyChotics - (Haloperidol, Quetiapine, Risperidone)
D - AntiDepressants - (SSRIs, TCA)
D - Diuretics
E - AntiEmetics (Ondansetron)
Rhythm control - what is the treatment? (post cardioversion) (memory trick)
Flecainide (avoid in heart disease)
Amiodarone
Beta blocker = FIRST LINE
Propafenone (avoid in heart disease)
Dronedarone (avoid in heart disease)
Sotalol (not as first line)
Pneumonic = FAB rhythms PD
Cardioversion - what are the types? what does it do? what drugs are
recommended?
Pharmacological or electrical
Cardioversion = restores sinus rhythm
Cardiology 4
, For pts with new onset AF - treated with a rhythm control strategy
Flecainide (NOT with for pts with IHD or structural heart problems)
Amiodarone (if structural or IHD)
When do you give electrical cardioversion?
If AF >48h = electrical preferred over pharmacological
But delay until pt has been given fully AC for at least 3 weeks = due to risk
of stroke with EC
Not possible = Heparin immediately before cardioversion
Oral AC (DOAC 1st) = given after cardioversion & continued for at least 4
weeks
Amiadarone in electrical cardioversion?
4 weeks before
Continue for up to 12 months after electrical cardioversion = maintain sinus
rhythm
NOT RECOMMENDED LONG TERM FOR RATE CONTROL
Stroke & Bleeding Risk Calculators
What assessment tool is used to assess stroke & bleeding risk?
CHA2DS2 VASC - stroke
ORBIT= bleeding
What are the risk factors involved in the STROKE assessment?
CHA₂DS₂-VASc
CHF = 1
HTN = 1
Age ≥75 = 2
DM = 1
Stroke/TIA/PE/DVT = 2
Vascular disease (previous MI/arterial disease/aortic plaque) = 1
Cardiology 5
, Age = 65-74 = 1
Sex Female = 1
What risk factors are involved in both BLEEDING assessments? (dropdown)
ORBIT
What is the interpretation of this?
0-2 = low risk
3 = medium risk
4-7 = high risk
Older than 74 = 1
Reduced Hb = 2
Bleeding history (GI bleed, intracranial bleed or haemorrhage
stroke) = 2
Inadequate renal function (GFR <60) = 1
Treatment with anti platelet = 1
Max score = 7
HASBLED
What is the interpretation of results?
0-2 = low risk of bleeding
≥ 3 high risk
HTN = >160mmHg systolic
HTN = 1
Abnormal renal/liver function = 1 or 2
Stroke = 1
Bleeding tendency = 1
Labile INR = 1
Elderly/Age (>65) = 1
Drugs (concomitant aspirin, NSAID or alcohol etc) = 1 or 2
Max score = 9
Cardiology 6
