Thread by @runthelistpod

⁉️Did you know the left atrial appendage can be described as chicken wing🍗, cactus 🌵, windsock, & cauliflower morphology⁉️

Full 🧵on 💘Atrial Fibrillation💘

🎧RTL Ep. 23: bit.ly/3b6svs0

Thanks to @Gurleen_Kaur96 for this week's tweetorial!

https://twitter.com/i/status/1352757712472436737

🥇First, let's review the basics of atrial fibrillation (A.fib)

✨Most common cardiac arrhythmia✨

Etiology:
-🎆Rapid firing from foci in pulmonary vein triggers reentrant waves🎆

EKG:
-RR intervals have no pattern ➡️ irregularly irregular
-No distinct P waves

An aside on terminology 📅:

🔹Paroxysmal: self-terminated in < 7 days

🔹Persistent: > 7 days or need cardioversion

🔹Long-standing persistent: > 1 year

🔹Permanent: no attempt to restore/maintain sinus rhythm

🔹A.fib with rapid ventricular response (RVR): >110-120 bpm

A.fib can be asymptomatic or present with:

💓Palpitations, chest discomfort/angina
🫁 SOB, exercise intolerance
😫Fatigue, weakness
🧠Pre-syncope
💔Heart failure (tachycardia mediated cardiomyopathy - dilated LV, reversible)

🏴Causes of A.fib?

☠️PIRATES☠️

P ulmonary 🫁: PE, COPD

I schemia (ACS), I diopathic, I atrogenic

R heumatic heart (valvular)

A nemia, A trial myxoma

T hyrotoxicosis 👔

E thanol 🍷, E levated BP

S epsis, S leep apnea 😴, S ick sinus

Time for a quick quiz! 📝

Every patient with rapid A.fib needs an inpatient echocardiogram

FALSE!

🔥Indications for echo🔥:

🟣First episode of A.fib
🟣New onset concurrent HF (HFpEF and A.fib can be vicious twins!)
🟣Suspected new onset ischemia
🟣TEE to rule out thrombus before cardioversion

Check out @medicine_strong video on acute A.fib: bit.ly/3iFpCAh

🏥A.fib Management🏥

Assess for instability: hypotension, lactate, AMS, decreased urine output

Unstable --> ⚡️Synchronized Cardioversion⚡️

🏃‍Rate control🏃: beta-blocker, Ca channel blocker, amiodarone

🎯Goal: <80bpm if symptomatic/HF, <110bpm if normal LV and asymptomatic

Now, let's consider you are seeing a patient with an irregularly irregular rhythm and an EKG as shown below 👇

(EKG from @medicine_strong)

Which agent would you chose for initial acute *rate* control?

🏃💊🏃

Answer?

🔥Procainamide🔥

EKG shows:
🔸irregularly irregular rhythm
🔹wide QRS complex
🔸rapid rate ➡️ pre-excited A-fib (A-fib + WPW)

Accessory pathway that bypasses AV node
◽️can NOT use AV nodal blocking agents; may trigger V.fib!
◾️use Procainamide or Ibutilide instead

🥁What about Rhythm control?🥁

Use if:
🔹A.Fib is causing hemodynamic instability
🔸Symptoms despite adequate rate control, and/or
🔹Unable to tolerate rate-controlling agents

💊Flecainide, propafenone, sotalol, dronedarone, dofetilide, amiodarone💊

🌩️To Cardiovert or not to Cardiovert🌩️

That is the question 🧐

Cardiovert if:
📢Anticoagulation > 3 weeks
📢Less than 48 hours of A.fib
📢TEE does *not* show clot

💊Continue anticoagulation (see below) for 4 weeks after cardioversion

🩸To anticoagulate or not🩸

CHA₂DS₂-VASc score🆚HAS-BLED score

if CHA₂DS₂-VASc >2 men, >3 women ➡️ anticoagulate💊

Non-valvular A.fib:
-DOAC (apixaban, rivaroxaban)

Valvular A.fib:
-Warfarin

To prevent bleeding, no antiplatelets
If on antiplatelets, use PPI to⬇GI bleed

Don't forget rheumatic or acquired mitral stenosis when thinking of "valvular" A.fib!

Check out this awesome case and explanation by @jelevenson 👇

https://twitter.com/jelevenson/status/1350865284446490626

Left atrial appendage (LAA) = embryonic LA remnant
🔹typically has biphasic emptying⌚️

With A.fib ➡️Virchow's triad:
📐endocardial dysfunction
📐abnormal blood stasis
📐altered hemostasis
+
📉Reduced LAA peak flow velocity ➡️ thrombus

Thrombus in LAA leads to stroke risk! 🧠

Interestingly, some studies show that LAA morphology can be associated with stroke risk

LAA morphologies?

4 most common:
🍗chicken wing
🌵cactus
🌪️windsock
🥦cauliflower

Non-chicken wing morphology may increase risk of thrombus & require oral anticoagulation

🔪Can perform percutaneous catheter-based endocardial and epicardial LAA closure🔪

Devices such as⌚️WATCHMAN⌚️
▪️PROTECT-AF trial showed non-inferiority to warfarin

✨Summary for A.fib✨

1. Workup:
-reversible causes (anemia, thyroid, sleep apnea, alcohol, BP, decomp HF)
-💘cardiac causes (LV function, valvular disease, etc)

2. Goals:
-symptom control vs. prevention

3. Think🤔:
-Rate vs Rhythm control and anticoagulation

RTL handout ⤵️

Download the one-page A Fib RTL handout (free!) here:
runthelistpodcast.com/s/RTL_Afib_Han…

Listen to Episode 23: Atrial Fibrillation 👇

🍎podcasts: apple.co/2XhpRIU
🎶Spotify: spoti.fi/3caXvV3
RTL🕸️: bit.ly/3b6svs0

#FOAMed #MedEd

REFs (1/3)
[2]osmosis.org/learn/Atrial_f…
[2] ] Mikhail Torosoff & Steven A. Fein. "I Read ECGs An interactive practical guide to the electrocardiogram interpretation"
[3,5,12,14,16,18]pubmed.ncbi.nlm.nih.gov/32273035/
[3]litfl.com/atrial-fibrill…
[4]aafp.org/afp/2011/0101/…

REFs (2/3)
[4]pubmed.ncbi.nlm.nih.gov/31146871/
[5]ahajournals.org/doi/10.1161/ci…
[7,8-11]
[5] jacc.org/doi/full/10.10…
[8,12]ahajournals.org/doi/10.1161/ci…
[11] acc.org/education-and-…
[11]slideshare.net/ramachandrabar…
[12]uptodate.com/contents/rhyth…
[13]aafp.org/afp/2016/0915/…

REFs (3/3)
[16,17]ahajournals.org/doi/full/10.11…
[18]jacc.org/doi/full/10.10…
[18]pubmed.ncbi.nlm.nih.gov/27816552/

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