OSCE — assessment and management of new atrial fibrillation · MBBS OSCE

Brief (to candidate)

A 72-year-old man is referred from the OPD with 3 days of palpitations and breathlessness. His pulse is irregularly irregular at 130/min, BP 110/70, SpO₂ 96% on air; he is alert with no chest pain. ECG shows atrial fibrillation. He has hypertension, type 2 diabetes and a prior TIA. You have 8 minutes to assess him, stratify his stroke and bleeding risk, and outline immediate and definitive management.

Candidate instructions

Take a focused history and examine, using an ABCDE approach; first assess for haemodynamic instability.
Confirm the diagnosis and classify the AF (valvular vs non-valvular).
Stratify stroke risk (CHA₂DS₂-VASc) and bleeding risk (HAS-BLED), reproducing the components.
Outline anticoagulation (drug, dose, route) and a rate-control strategy with doses.
State your disposition and safety-net / follow-up advice.

Examiner checklist (mark each domain / 10)

Domain	Key actions expected
ABCDE / instability check	Confirms he is currently stable (BP 110, no chest pain/HF); states that instability (hypotension, HF, angina) would mandate emergency synchronised DC cardioversion^[1]
Diagnosis & classification	Confirms AF on ECG (irregularly irregular, no P waves, f-waves); states non-valvular (no mitral stenosis/mechanical valve) → DOAC-eligible^[2]
Stroke risk — CHA₂DS₂-VASc	Reproduces all components; calculates score ≥ 4 (HTN, DM, prior TIA = 2, age 65–74) → anticoagulation indicated^[5]
Bleeding risk — HAS-BLED	Reproduces components; states ≥ 3 = high bleeding risk but does NOT deny anticoagulation — fix modifiable factors (BP, NSAIDs)^[6]
Anticoagulation	DOAC preferred (e.g. apixaban 5 mg BID, or rivaroxaban 20 mg OD); warfarin only for valvular AF; gives a drug + dose^[1]
Rate control	Beta-blocker OR non-DHP CCB first-line (e.g. bisoprolol 5 mg OD or diltiazem); target < 110 bpm; avoids CCB if HFrEF^[2]
Investigations	TTE (already done), TFTs, U&E, FBC, LFTs, coagulation; consider TOE if cardioverting
Communication & safety-net	Clear ABC-pathway plan; modifiable risk factors (BP, weight, sleep apnoea, alcohol); adherence; red flags (chest pain, syncope, stroke)^[1]

Model key actions

Instability first — if hypotensive / in HF / ischaemic → emergency synchronised DC cardioversion (biphasic 120–200 J), not drugs.^[1]
CHA₂DS₂-VASc ≥ 2 → anticoagulate; this patient scores ≥ 4 → apixaban 5 mg BID (or equivalent DOAC); no INR monitoring needed.^[5]^[1]
HAS-BLED flags correctable factors (control BP < 160 systolic, stop NSAIDs) — do not withhold anticoagulation.^[6]
Rate control with a beta-blocker (e.g. bisoprolol) to < 110 bpm; consider early rhythm control if symptomatic (EAST-AFNET 4).^[2]
If cardioverting electively: ≥ 3 weeks anticoagulation before AND ≥ 4 weeks after (or TOE-guided), regardless of score.^[2]

Common errors

Not checking for / stating the instability criteria (the cardioversion mandate).
Withholding anticoagulation because HAS-BLED is high.
Recommending a DOAC in a (hypothetical) valvular/mechanical-valve case — warfarin only.
Giving a non-dihydropyridine CCB when LV function is impaired.
Giving aspirin instead of an anticoagulant for stroke prevention.
Not addressing modifiable risk factors (BP, weight, sleep apnoea, alcohol).

References4Show

[1]Joglar JA, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Circulation, 2024.PMID 38033089
[2]Hindricks G, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation. European Heart Journal, 2021.PMID 32860505
[5]Lip GYH, et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation (CHA₂DS₂-VASc). Chest, 2010.PMID 19762550
[6]Pisters R, et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in atrial fibrillation. Chest, 2010.PMID 20299623