GEM - atrial fibrillation including reference to NICE guidance

Atrial Fibrillation GPnotebook Educational Module (GEM)

Important messages regarding Cardiovascular Disease and Primary Care (1):

• cardiovascular problems are an important cause of morbidity and mortality
• management of the risk factors for cardiovascular problems are an essential part of health promotion activity in primary care
• all general practitioners should be competent in the management of cardiovascular emergencies in primary care
• accurate diagnosis of symptoms that may potentially be due to cardiovascular causes is a key competency for general practice

This GEM cannot cover the whole 'knowledge base' of the nMRCGP exam. However this GEM seeks to highlight important areas of knowledge for the primary care clinician (GP or GP registrar).

Atrial Fibrillation

Atrial fibrillation is an atrial rhythm that is ineffective, chaotic, irregular and rapid - atrial rates may vary between 300 and 600 beats per minute.

This condition results in an irregular ventricular rate because the impulses from the atria approach the atrioventricular node from varying angles and at varying intervals. Atrial fibrillation is often seen in the elderly and generally is asymptomatic. If atrial fibrillation occurs when there is a large atrium, for example in mitral stenosis, then this is a predisposing factor to the development of thromboembolism.

How common is atrial fibrillation?

• GPN reference

Causes of atrial fibrillation may be considered in terms of common and rare causes. Atrial fibrillation may result from any of the following changes in the atria:

• dilatation
• increased muscle mass
• inflammation, infiltration and fibrosis Can you think of some common causes of atrial fibrillation?
  • GPN reference

ECG changes in atrial fibrillation. In an ECG for a patient atrial fibrillation there may be both irregular and normal QRS complexes observed. What are the characteristic ECG changes seen in atrial fibrillation?

• GPN reference

When is echocardiography indicated in the context of atrial fibrillation?

• GPN reference

In a patient who has acute onset AF and is haemodynamically unstable, is electrical cardioversion indicated rather than pharmacological cardioversion?

• GPN reference

When is rate-control a better treatment target than rhythm control in a patient with chronic AF?

• GPN reference

In patients with Wolff-Parkinson-White (WPW), are AV-node blocking agents such as digoxin and verapamil the treatment of choice?

• GPN reference

Paroxysmal atrial fibrillation

Paroxysmal atrial fibrillation is often more symptomatic than stable fibrillation, and it is often difficult to distinguish from frequent atrial ectopics.

Possible precipitants of atrial fibrillation in the context of paroxysmal atrial fibrillation include caffeine and alcohol

If regular drug therapy is initiated in the management of atypical atrial fibrillation, then, in the context of structural heart disease, what is the usual first-line treatment

• GPN reference

Antiplatelet or anticoagulation treatment for patients in atrial fibrillation

Patients with atrial fibrillation are assessed as to whether there is a high, moderate or low risk of stroke related to various factors.

• GPN reference

Further information:

• Atrial fibrillation section of GPnotebook
• Wolff-Parkinson-White section of GPnotebook
• Warfarin section of GPnotebook

Reference:

1. Royal College of General Practitioners. Curriculum Statement 15.1 Cardiovascular Problems.