A 62-year-old woman presents with sob and palpitations, ongoing for few hours. 1 year hx of feet and ankle swelling. Other symptom include DIB while lying down. She is a known alcoholic.

A chest radiograph shows evidence of cardiac enlargement. What is the SINGLE most likely cause of her worsening condition? A. Ventricular tachycardia B. Paroxysmal supraventricular tachycardia C. Ventricular fibrillation D. Atrial fibrillation E. Ventricular ectopic

Simplified/ Key word/Clinical pearl- Ankle swelling and orthopnoea are features of heart failure. These features in combination with the history of alcoholism gives us the hints of an alcoholic cardiomyopathy which is a type of dilated cardiomyopathy.

Atrial fibrillation is the most common arrhythmia that develops in patients with dilated cardiomyopathy.

AF is a supraventricular tachyarrhythmia (BMJ 2019)

Note- Irregular supra ventricular tachycardia is usually AF.

In Acute AF under 48hrs, try to control rate and rhythm-

chronic AF- after 48hrs- control the rate

Rate control drugs- Beta blocker, Calcium channel antagonist (diltiazem/verapamil) and digoxin
The main stay of treatment in AF is rate control and not cardioversion.
AF needs anticoagulants- Warfarin to prevent embolism, Aspirin if pt younger than 65yrs and no htn, no dm, no lv dysfunction, no valvular heart disease and no MI/TIA
PEARL- Use the CHAD2 SCORE to decide whether pateint needs to be on aspirin or warfarin

For paroxysmal AF- flecanaide (pill in the pocket), sotalol, anticoagulation . Sotalol is usually initiated and titrated up to an appropriate dose in secondary care. However, a primary care practitioner may be expected to continue prescribing sotalol

The appropriate investigation for Paroxysmal AF is 24 hour ECG/amubulatory ECG

Acute AF- less than or equal to 48hrs duration

if patient is very ill or heamodynamically unstable do electrical cardioversion

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