What would you do if a patient with history of afib taking DOAC and then have a hemorrhagic stroke? Would you make any adjustment to their DOAC therapy?

When is there an indication for both Antiplatelet and Anticoagulant? I always thought if had CAD with PCI and became atrial fib would be on both and not just on antiplatelets.
Response: You definitely need an anticoagulant if your patient meets criteria based on the CHADS65 tool. If they have stable CAD, a DOAC is sufficient. You do not need to add aspirin.

Is cannabis a risk factor for AFib?
Response: Not that I am aware of. There are some reports that it may decrease the risk! We do not recommend using it as a treatment however!

A word on physical exertion and AFib. Physical exercise?
Response: Extreme physical activity is a risk factor. There patients are hard to treat because of their slow resting heart rate. Ablation is considered early for this group.

It sounds like ablation is recommended for all patients newly diagnosed with AFib. Should we be referring all patients to cardiologists upon diagnosis?
Response: I would say yes. Early rhythm control for new PAF is now the way to go unless there was a clear reversible cause.

Can you speak to the reliability/effectiveness for the use of artificial intelligence in screening for AFib?
Response: Not my area of expertise but AI is already changing the landscape. Portable devices are better and better at detecting and accurately diagnosing AFib.

Can we start anticoagulation/rate control while awaiting echo?
Response: Absolutely yes! The chance you pick up a case of surprise valvular AFib is very low.

Working with a young patient with CHADS 0 and no symptoms, but persistent AFib, would this patient be a rhythm control candidate/ ablation candidate?
Response: I would discuss with patient but strongly consider it. If the AFib is left alone, it will most likely become persistent, then permanent and eventually can cause heart failure

We were taught if AFib is first detected in outpatient clinic, to send to ER. Then we were taught to do rate control and send as outpatient. What is the current recommendation and given the state of corridors for referral, what would be the best way to refer in our MUHC system?
Response: You don’t need to send a patient with new AFib to the ER if they are tolerating their arrhythmia. You can start the DOAC +/- rate control agent in your office. Only refer those whose rate is fast and highly symptomatic patients. Exception: very recent onset AFib - these patients would be considered for cardioversion early.

How can we tell if patient is paroxysmal AFib, persistent AFib, longstanding persistent AFib?
Response: It all has to do with the duration of symptoms. If episode ended < 7 days, paroxysmal. 7 days to 1 year = persistent. > 1 year with no plan to try rhythm control = permanent.

How do you prescribe/counsel pill in pocket method?
Response: Difficult to answer in this forum. I recommend checking out the guidelines. Essentially, you prescribe an AV node blocker + a class 1C AAD (flecainide or propafenone). The dose of the AAD is usually higher than the maintenance dose. Please consult the guidelines document!

Which montitoring is indicated for which antiarrythmic drugs? Which are safe for initiation in office?
Response: Flecanide, sotalol, propafenone, amiodarone, dronedarone can all be started in the office. Most need QT monitoring. The 1C agents need monitoring of the QRS duration. Amiodarone needs monitoring of thyroid, liver, and lung function as well.

Can we Rx flecanide in family med and perform the follow-up? Is a repeat echo required post flecanide? Can we Rx flecanide without BB?
Response: Typically, flecanide is prescribed by cardiology. If you start it, start low dose (50mg PO bid) and perhaps refer the patient to cardio. Always make sure to prescribe it WITH an AV node blocker!

What is wait time to get a catheter ablation ( long wait? ) and do you stop the doac/asa for procedure and if so, how long?
Response: 1 year. No

If you treat a reversible cause for AFib (ex : sepsis), do you need to anticoagulate after the triggering event is resolved if the CHADS65 is positive?
Response: Case by case basis. I often use the echo findings to help me decide. Is there atrial enlargement? Is there valve disease (e.g. MR)? How positive is the CHADS score?

When is it hard to tell AFib from atrial tachycardia in a lead one Kardia tracing, with P waves that aren’t apparent, and mostly regular rhythm?
Response: Atrial tachycardia is typically regular with P waves. AFib has no P waves and is completely irregular.

Any recommendations for DOAC in high obesity BMI > 50?
Response: Most recommend usual doses.

For patients complaining of bright red blood per rectum in a walk in clinic and known AFib on anti-coagulants, how long can we hold the anti-coagulants?
Response: There’s rarely an issue stopping the anticoagulant for a few days. Sometimes we need to stop for longer. Typically hospitalized patients have their DOAC stopped for 1-2 weeks. It all depends if the source has been treated.

Different scoring CHADS-VASc vs Canadian CHADS65, are we over anticoagulating based on score used?
Response: Use the score you feel most comfortable with. There are minor differences. I lile the CHADS65 because it’s easy.

Patients with PAD and A-fib- Do you continue anti platelet with DOAC?
Response: I don’t.

How do we know if an asymptomatic aging patient with a pacemaker has AFib requiring anticoagulation?
Response: Controversial area. Recent research suggests that pacemaker detected AFib, especially in the absence of symptoms is not as risky as clinically evident AFib. We might consider anticoagulating with prolonged episodes and a high CHADS however.

Whats the role of ordering Coagulation profile as a baseline and if INR is elevated, would it sway you from angicoagulating the patient?
Response: A high INR would need to be investigated. If the INR is significantly elevated, the patient may have a hematologic disorder. I would hold off before proceeding with anticoagulation.

BP control in octogenerians is it safer to leave them around 150 SBP? Some previous studies suggested so any newer recomendations?
Response: Not that I am aware of. In high risk patients, we sometimes aim for lower (SPRINT trial) but older patients are at higher risk of orthostatic hypotension.

How accurate is automated BP measurment in AFib?
Response: It depends on how irregular the AFib is. Sometimes, false meaurements can occur. It is recommended to measure more than once or twice.