Atrial Fibrillation

Scenario 

A 72 year old man is 5 days post endovascular AAA repair and develops shortness of breath, tachycardia and palpitations. The nurses ask you to see the patient as he looks acutely unwell. 

Observations

Respiratory rate 25

Oxygen saturation 91% on 2L NC 

Heart rate 135 BPM

Blood pressure 113/70 mmHg

Temperature 36.8C

How would you assess this patient?

Upon receiving the call to assess the patient, I would take the following steps in an A-E approach and CCrISP triple assessment. 

Airway

• Assess for any signs of airway obstruction

Breathing

• Place patient on 15L non-rebreather mask

• Monitor oxygen saturation and respiratory rate

• Look for cyanosis or increased work of breathing

  
  

• Perform focused respiratory examination including trachea, percussion, expansion, and auscultation

• Obtain ABG and CXR if necessary

Circulation

• Assess warmth and perfusion

• Monitor blood pressure and heart rate

• Perform focused cardiovascular examination including pulse regularity, blood pressure, jugular venous pressure (JVP), heart sounds, and signs of overload

• Review urine output and fluid balance

• Establish intravenous access

• Perform blood tests including G&S

• Obtain an ECG

Disability

• Assess Glasgow Coma Scale (GCS)

• Check blood glucose levels

• Evaluate pupil responses

• Monitor temperature and consider blood cultures if indicated

Exposure

• Assess for leg swelling and signs of deep vein thrombosis (DVT).

• Inspect lines and wound site for any signs of infection or complications.

After initial assessment

• Review operative and medical notes.

• Monitor observations and fluid balance charts.

• Consider escalation to senior medical staff if necessary.

Following initial A-E assessment what else would you like to review? 

Following the initial A-E assessment, additional review specific to atrial fibrillation and the recent endovascular AAA repair would involve a comprehensive CCrISP Triple Assessment:

Operation Note Review:

• Examine details of the recent endovascular AAA repair surgery, focusing on any intraoperative complications or findings that may contribute to the development of atrial fibrillation or exacerbate existing cardiac conditions.

Medication Chart:

• Verify if the patient is prescribed appropriate medications post-surgery, including anticoagulants for atrial fibrillation management and medications to control heart rate or rhythm.

Review of Blood Results and Imaging:

• Evaluate recent laboratory findings, including electrolyte levels, renal function, and cardiac enzymes, to identify any abnormalities exacerbating atrial fibrillation or indicating other complications post-surgery.

• Assess imaging studies such as chest X-rays or CT scans to detect any cardiac structural abnormalities or evidence of postoperative complications affecting cardiovascular function.

Completing the CCrISP Triple Assessment tailored to atrial fibrillation and the recent surgical intervention allows for a comprehensive evaluation, aiding in the development of an appropriate management plan addressing both the acute symptoms and underlying cardiac issues.

His airway and breathing is unremarkable and his ECG is shown – please interpret the ECG and tell me the diagnosis? 

• ECG shows:

  • Absent p-waves

  • Variable ventricular rate

• Leading to a diagnosis of ATRIAL FIBRILLATION

Note: state you would want to compare to previous ECG for comparison 

What investigations would you want to order for this patient?

Bedside Tests

• VBG for lactate levels

• Blood cultures if patient septic

• Urine MC+S

Blood Tests

• Full Blood Count (FBC)

• Serum electrolytes (U&Es)

• Magnesium levels (Mg2+)

• Troponin levels

• Thyroid Function Tests (TFTs)

Radiological Investigations

• CXR

Further Investigations (Longer Term):

• 24-hour Holter monitor tape for continuous cardiac rhythm monitoring

• Echocardiogramfor cardiac structural assessment

What are the causes for acute atrial fibrillation?

Pre-operative

M  Mitral valve disease / previous cardiovascular disease

I  Idiopathy

T  Thyroid disease

R  Really old

A  Alcohol

L  Lung disease

Post-operative (5Hs)

H  Horrible bugs (Sepsis)

H  Hypovolaemia

H  Hypoxia 

H  High or low electrolytes

H  Heart issues (MI)

Bloods: FBC, U&Es, Mg2+, troponin, TFTs

How should acute atrial fibrillation be managed the post-operative patient?

Managing acute atrial fibrillation in the post-operative patient involves addressing both the acute symptoms and underlying causes:

Treatment of Underlying Cause

• Sepsis: Initiate the sepsis six protocol, including antibiotics and intravenous fluids.

• Hypoxia: Administer supplemental oxygen to maintain adequate oxygenation.

• Hypovolaemia: Address hypovolaemia with appropriate fluid resuscitation.

• Cardiovascular Issues (e.g., myocardial infarction): Collaborate with cardiology for timely evaluation and management.

• Electrolyte Disturbances: Correct any electrolyte imbalances contributing to atrial fibrillation.

Early Collaboration with Cardiology

• Discuss with cardiology for early involvement and guidance.

• Consider the need for:

  • Rate control: Utilise medications such as bisoprolol to control ventricular rate.

  • Rhythm control: Evaluate options such as digoxin or amiodarone to restore sinus rhythm.

By addressing both acute symptoms and underlying causes, along with timely involvement of cardiology for specialized management, optimal care can be provided to post-operative patients with acute atrial fibrillation.

When is cardioversion necessary?

Cardioversion, either chemical or electrical, is urgently indicated in cases of rapid atrial fibrillation (AF) when patients exhibit adverse signs or symptoms such as:

• Chest pain

• Hypotension

• Decreased level of consciousness (GCS)

• Marked tachycardia (>140bpm)

How would you decide if this patient required long term anti-coagulation therapy? 

To determine the necessity of long-term anticoagulation therapy for this patient, the CHA2DS2-VASc score is commonly employed. This scoring system evaluates various risk factors to estimate the risk of stroke in patients with atrial fibrillation (AF). Here's how it works:

• Congestive Heart Failure (1 point): If the patient has congestive heart failure, they score 1 point.

• Hypertension (1 point): If the patient has hypertension, they score 1 point.

• Age ≥75 years (2 points): Patients aged 75 years or older score 2 points.

• Diabetes Mellitus (1 point): If the patient has diabetes mellitus, they score 1 point.

• Stroke or TIA history (2 points): Patients with a history of stroke or transient ischaemic attack (TIA) score 2 points.

• Vascular Disease (1 point): If the patient has vascular disease (e.g., previous myocardial infarction, peripheral artery disease, aortic plaque), they score 1 point.

• Age 65-74 years (1 point): Patients aged 65 to 74 years score 1 point.

• Sex Category (Female) (1 point): Female patients score 1 point.

The total score determines the patient's risk of stroke. For patients with a CHA2DS2-VASc score of 2 or more (males) or 3 or more (females), anticoagulation therapy with agents such as warfarin or direct oral anticoagulants (DOACs) is recommended to reduce the risk of stroke in atrial fibrillation.

In this patient's case, you would calculate their CHA2DS2-VASc score based on their medical history and risk factors. If the score indicates a moderate to high risk of stroke, long-term anticoagulation therapy would likely be recommended [Link to Lip et al paper, 2010]

What does NICE recommend as first-line anti-coagulation in patients with AF? 

NICE guidelines on Atrial Fibrilation recommend DOACs as the first-line treatment for anticoagulation in patients with atrial fibrillation (AF) who have a moderate to high risk of stroke. DOACs include medications such as apixaban, dabigatran, edoxaban, and rivaroxaban. These medications have been shown to be as effective as warfarin in preventing stroke and have a lower risk of bleeding complications.

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