CARDIOLOGY

ATRIAL FIBRILLATION

Introduction

5 min

Introduce yourself and the group

Provide rationale for the session and relevance to clinical practice

Outline learning objectives:

Identify atrial fibrillation on an ECG
Assess whether a patient is stable or unstable on the ALS tachycardia algorithm
Explain the mechanism of actions and side effects of common medications used in the treatment of AF
Understand the information to counsel a patient starting anticoagulation for AF

Explain structure of session

Total time:

60 min

Number of students:

1-5

Grade of students:

3rd to 5th year medical students

Created by:

Dr Beth Brockbank

Uploaded:

16th September 2019

Last updated:

16th September 2019

Resources needed for this session:

Pen, paper, prescription chart, access to a defibrillator (for illustration purposes only)

Students can scan the QR code opposite to view all investigation results on their phone as you work through the session.

Resources linked to this session:

Activity 1: History Taking and Examination Skills

10 min

Before the student(s) goes to take a history from the patient, discuss the key points students should aim to clarify from the history.

These may include:

Whether the patient had any symptoms and when they started
Red flag features such as collapse or ischaemic chest pain
Clues as to precipitating causes from history and examination
Signs suggesting complications of tachycardia on examination

Ask the student(s) to take a focused history and perform a focused examination on the patient. This can be observed if time and capacity of tutor allows.

Activity 2: Diagnostic Reasoning

5 min

Ask the students to present a brief summary of their history and examination. Feedback on presentation style (max 1 minute).

Discussion points:

Why is the time of onset important?
What are the key investigations to perform on this patient and why?

Activity 3: Bedside Tests

5 min

Ask the student(s) to review the patient's ECG if available. If none is available, use the example below. Students can scan the QR code to view the ECG on their phone if needed.

For more junior students - ask them to present the ECG in a systematic manner
For more senior students - ask them to point out the main features of AF seen on the ECG

Activity 4: Initial Assessment

10 min

Briefly recap with students an initial approach to management of the acutely unwell patient - the ABCDE assessment. Discuss:

What features may suggest instability of a patient with atrial fibrillation?
How would an unstable tachycardic patient be managed?

Reference the Resuscitation Council adult tachyarrhythmia (with pulse) algorithm -copied below - and the QR code opposite links to this to allow students to view on their phone.

Go and find the defibrillator on the ward. Demonstrate how you would set up the defibrillator to cardiovert a patient. Students can watch the BHF video on cardioversion in their own time to consolidate their learning (see references).

Activity 5: Prescribing

10 min

The algorithm has mentioned a number of drugs, including beta blockers e.g. bisprolol, diltiazem, digoxin and amiodarone.

Ask the student(s) to consider for each of the above medication:

Mechanism of action
Side effects - short and long-term
Which of these are used in the acute management of atrial fibrillation and are their any factors that may influence your choice?

Depending on the availability of tutors, this could be run as a self-directed learning task - allow students time to research the answers and present back key findings. The QR code opposite links to the BNF online site, if required.

Activity 6: Stroke Prevention in Atrial Fibrillation

15 min

Discuss with the student(s):

Why do clots form and why do we want to prevent them?
How can we measure someone’s risk of stroke and bleeding?

Ask them to calculate the CHADSVASc and HASBLED score for the patient they have seen. The QR code opposite links to the mdcalc online calculator.

What options for anticoagulation exist? What are the risks and benefits of DOACs and warfarin? What might influence someone's decision?

Ask the student(s) to consider how they might counsel the patient regarding anticoagulation. They could practice on each other, or with the patient if capacity of the tutor allows.

Ask the student(s) to meet with the ward pharmacist for further advice on information giving in the situation. Consider what additional resources they could use e.g. leaflets, warfarin information card and monitoring booklets.