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Atrial Fibrillation

AF

Atrial fibrillation is a clinical condition characterized by a rapid and irregularly regular atrial rhythm of the heart. This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. The irregular atrial rhythm in atrial fibrillation raises the risk for embolic stroke among susceptible patients.


Presentation

Majority of patients will not present with any symptoms at all. Only mild palpitations, chest discomfort, light headedness, dyspnea, and generalized weakness are subjectively felt by the patients. Upon physical examinations, pulses and auscultatory findings will reveal an irregularly regular rhythm. Pulses may not coincide with ventricular rates because the pumping may not generate sufficient blood or force to produce peripheral pressure.

Dyspnea
  • This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. The irregular atrial rhythm in atrial fibrillation raises the risk for embolic stroke among susceptible patients.[symptoma.com]
  • He denies dizziness, dyspnea, and chest pain, and says he sleeps comfortably on one pillow each night. His history is significant for diabetes mellitus type 2, hyperlipidemia, and hypertension.[medbullets.com]
  • Third, although the rates of incident HF during follow-up in patients with and without diabetes were similar, it is noteworthy that dyspnea, exercise intolerance, and fatigue, symptoms often due to HF, were reported approximately 10% more frequently by[onlinejacc.org]
  • Although up to 90% of AF episodes may not cause symptoms, [ 50 ] many patients experience a wide variety of symptoms, including palpitations, dyspnea, fatigue, dizziness, angina, and decompensated heart failure.[emedicine.medscape.com]
  • More often, however, patients report nonspecific symptoms such as fatigue, dyspnea, dizziness, and diaphoresis. Palpitations are a common feature.[clevelandclinicmeded.com]
Coronary Artery Disease
  • Coronary Artery Disease Coronary artery disease (CAD) refers to the narrowing or blockage of arteries in the heart. It is the most common cause of death among men and women in the United States.[activebeat.com]
  • CASE REPORT Our patient was a 77-year-old woman with dextrocardia and situs inversus, with a history of permanent AF due to severe coronary artery disease (CAD), who suffered from recurrent CHF exacerbations from permanent AF with moderate to rapid ventricular[ncbi.nlm.nih.gov]
  • artery disease, and peripheral artery disease (PAD).[ncbi.nlm.nih.gov]
  • Arial fibrillation is strongly associated with cardiovascular diseases like coronary artery diseases (CAD), congestive heart failure (CHF) and diabetes mellitus.[symptoma.com]
  • Possible causes of atrial fibrillation include: High blood pressure Heart attacks Coronary artery disease Abnormal heart valves Heart defects you're born with (congenital) An overactive thyroid gland or other metabolic imbalance Exposure to stimulants[mayoclinic.org]
Fatigue
  • Because the ventricles no longer receive rapid signals from the atria, they don't have to work as hard and the symptoms of breathlessness and fatigue go away.[strokeassociation.org]
  • But you may feel Palpitations -- an abnormal rapid heartbeat Shortness of breath Weakness or difficulty exercising Chest pain Dizziness or fainting Fatigue Confusion AF can lead to an increased risk of stroke .[medlineplus.gov]
  • The primary symptoms of atrial fibrillation include racing heart rates, an irregular feeling of heart beats, fatigue, shortness of breath, mild chest tightness, and lightheadedness.[pathnetwork.org]
  • When symptoms do occur, they include: Intermittent palpitations Trouble breathing Chest pain Dizziness Fatigue Treatment Treatment for atrial fibrillation can include suppressive therapy with rhythm or rate control medications designed to prevent the[lifebridgehealth.org]
Weakness
  • Patient B, a 77-year-old man, presented 21 days post-atrial fibrillation ablation with left-arm weakness and altered mental status. An esophagram was performed and showed no evidence of an esophageal perforation.[ncbi.nlm.nih.gov]
  • This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. The irregular atrial rhythm in atrial fibrillation raises the risk for embolic stroke among susceptible patients.[symptoma.com]
  • A 79-year-old female who was 5 weeks post-ablation presented to a community emergency department with chest pain and a transient episode of left-arm weakness.[ncbi.nlm.nih.gov]
  • A 72-year-old man with severe aortic stenosis was admitted to our hospital with dysarthria and right upper limb weakness.[ncbi.nlm.nih.gov]
  • But you may feel Palpitations -- an abnormal rapid heartbeat Shortness of breath Weakness or difficulty exercising Chest pain Dizziness or fainting Fatigue Confusion AF can lead to an increased risk of stroke .[medlineplus.gov]
Hypothermia
  • Causes of ‘slow’ AF include hypothermia , digoxin toxicity , medications, and sinus node dysfunction .[lifeinthefastlane.com]
  • Noncardiovascular respiratory causes Pulmonary embolism , pneumonia, lung cancer, and hypothermia have been associated with AF. Drug and alcohol use Stimulants, alcohol, and cocaine can trigger AF.[emedicine.medscape.com]
Nausea
  • We report a previously healthy 58-years old female, admitted because of nausea, dizziness, somnolence, a left-sided hemiparesis and arterial hypotension. The electrocardiogram showed atrial fibrillation with ST-elevations and ST-depressions.[ncbi.nlm.nih.gov]
  • Some include: palpitations (a sensation of rapid and irregular heart beat), dizziness or lightheadedness, weak feeling, shortness of breath, chest pain and/or angina , nausea .[emedicinehealth.com]
Heart Failure
  • MMP-28 increased the performance of prognostic prediction of heart failure. Circulating MMP-28 was elevated in atrial fibrillation. MMP-28 may be related to atrial fibrillation and heart failure.[ncbi.nlm.nih.gov]
  • Because If channels were thought to be expressed solely in sinoatrial (SA) nodal tissue, ivabradine was not investigated in heart failure patients with concomitant AF.[ncbi.nlm.nih.gov]
  • In anticoagulated AF patients with therapeutic INR and first lifetime cerebrovascular event, congestive heart failure and hypercholesterolemia were associated with ischemic stroke/TIA and history of bleeding with ICH.[ncbi.nlm.nih.gov]
  • Heart failure. Atrial fibrillation, especially if not controlled, may weaken the heart and lead to heart failure — a condition in which your heart can't circulate enough blood to meet your body's needs.[mayoclinic.org]
  • Atrial fibrillation is the most common heart-rhythm disorder, affecting about 1.5% to 2% of the population with an increased risk of mortality and morbidity due to stroke, thromboembolism, and heart failure.[ncbi.nlm.nih.gov]
Heart Disease
  • Before taking ranolazine, on the background of conventional treatment of coronary heart disease, the patient developed stable angina and persistent left bundle branch block, atrial fibrillation.[ncbi.nlm.nih.gov]
  • The active prevention of heart diseases through a heart friendly diet, exercise, and lifestyle may prevent occurrence of an acquired atrial fibrillation.[symptoma.com]
  • Heart disease. Anyone with heart disease — such as heart valve problems, congenital heart disease, congestive heart failure, coronary artery disease, or a history of heart attack or heart surgery — has an increased risk of atrial fibrillation.[mayoclinic.org]
  • Ebstein's anomaly (EA) is a rare congenital heart disease characterized by "atrialization" of the right ventricle, due to apical displacement of the tricuspid leaflets into the right ventricle.[ncbi.nlm.nih.gov]
Palpitations
  • This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. The irregular atrial rhythm in atrial fibrillation raises the risk for embolic stroke among susceptible patients.[symptoma.com]
  • We report a 47-year-old woman with no previous medical history presented with intermittent palpitation for 3 days. The electrocardiography showed AF with rapid ventricular rate.[ncbi.nlm.nih.gov]
  • TOPIC Editors' Choice of Best Available Content This collection features the best content from AFP , as identified by the AFP editors, on atrial fibrillation and related issues, including anticoagulation therapy, antiplatelet therapy, arrhythmias, and palpitations[aafp.org]
  • Snapshot A 68-year-old male presents with palpitations, lightheadedness, and weakness. These symptoms appear to worsen with increased alcohol intake. Medical history is significant for hypertension being treated with hydrochlorothiazide.[medbullets.com]
  • Medical Definition of atrial fibrillation : very rapid uncoordinated contractions of the atria of the heart resulting in a lack of synchronism between heartbeat and pulse beat If you're experiencing chest pain, palpitations, lightheadedness or shortness[merriam-webster.com]
Chest Pain
  • ST elevations in II, III, and aVf, with reciprocal ST depressions in V2-5, occurred in association with chest pain just after balloon rewarming and deflation, and the patient's blood pressure fell to 50 mmHg.[ncbi.nlm.nih.gov]
  • One hour later, the patient complained of chest pain in combination with marked ST-segment elevation in the anterior leads.[ncbi.nlm.nih.gov]
  • However, patients with MVA experience chest pain, which in most cases tend to strengthen and increase the number of pain episodes, significantly deteriorating the quality of life of these patients.[ncbi.nlm.nih.gov]
  • On the eighth day after admission, the patient developed sudden onset of severe chest pain and evidence of acute myocardial infarction (AMI).[ncbi.nlm.nih.gov]
  • In many patients, it can also cause chest pain, heart attack , or heart failure .[medlineplus.gov]
Hypertension
  • RAS inhibitors use was associated with a significant reduction in the risk of LAAT in patients with hypertension and AF.[ncbi.nlm.nih.gov]
  • This patient was diagnosed with hyperkalemia, hypertension, and AF. He was treated with an intravenous infusion of calcium gluconate, insulin and dextrose, an oral kayexalate, and emergency hemodialysis.[ncbi.nlm.nih.gov]
  • […] year-old woman with dextrocardia and situs inversus, with a history of permanent AF due to severe coronary artery disease (CAD), who suffered from recurrent CHF exacerbations from permanent AF with moderate to rapid ventricular response with underlying hypertensive[ncbi.nlm.nih.gov]
  • For patients without significant valvular disease, decisions around anticoagulation therapy are first based on the presence of additional stroke risk factors, as measured by the CHA2DS2-VASc (congestive heart failure, hypertension, age 75, diabetes, prior[ncbi.nlm.nih.gov]
  • Age and hypertension were the only predictive factors for the development of AF. Management of AF was heterogeneous, primarily with anti-vitamin K agents but also antiplatelet therapy in a significant proportion of patients.[ncbi.nlm.nih.gov]
Stroke
  • This substudy included AF patients on OAC with first lifetime ischemic stroke/TIA or spontaneous ICH. A total of 1457 patients with 1290 ischemic strokes/TIAs and 167 ICHs were identified.[ncbi.nlm.nih.gov]
  • AF episodes were detected in 1 patient with stroke by Holter, and in 7 individuals (1 control and 6 strokes) by PoIP. There was no difference in the incidence of arrhythmias between the groups.[ncbi.nlm.nih.gov]
  • stroke, concomitant antiplatelet therapy, heart failure, prior stroke, history of hypertension, myocardial infarction (MI), coronary artery disease, and peripheral artery disease (PAD).[ncbi.nlm.nih.gov]
  • Atrial fibrillation is a major risk factor for ischemic stroke, increasing risk of stroke by as much as 5-fold.[ncbi.nlm.nih.gov]
  • The CHA2DS2-VASc Score was used to evaluate ischemic stroke risk in patients with AF.[ncbi.nlm.nih.gov]
Dizziness
  • We report a previously healthy 58-years old female, admitted because of nausea, dizziness, somnolence, a left-sided hemiparesis and arterial hypotension. The electrocardiogram showed atrial fibrillation with ST-elevations and ST-depressions.[ncbi.nlm.nih.gov]
  • This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. The irregular atrial rhythm in atrial fibrillation raises the risk for embolic stroke among susceptible patients.[symptoma.com]
  • But you may feel Palpitations -- an abnormal rapid heartbeat Shortness of breath Weakness or difficulty exercising Chest pain Dizziness or fainting Fatigue Confusion AF can lead to an increased risk of stroke .[medlineplus.gov]
  • This can cause problems including dizziness , shortness of breath and tiredness.[nhs.uk]
  • When symptoms do occur, there may be palpitations (awareness of a rapid heartbeat), fainting, dizziness, weakness, shortness of breath and angina pectoris (chest pain caused by a reduced blood supply to the heart muscle).[hopkinsmedicine.org]
Confusion
  • But you may feel Palpitations -- an abnormal rapid heartbeat Shortness of breath Weakness or difficulty exercising Chest pain Dizziness or fainting Fatigue Confusion AF can lead to an increased risk of stroke .[medlineplus.gov]
  • Heart palpitations Lack of energy Lightheadedness Confusion Chest discomfort Shortness of breath, even at rest Yes. When it becomes constant, you may need treatment.[lifelinescreening.com]
  • Others experience: Palpitations: uncomfortable feeling that the heart is racing, beating irregularly or fluttering Fatigue Dizziness Shortness of breath Weakness Lightheadedness Confusion Problems exercising Sweating Chest pain or pressure (a medical[umm.edu]
  • However, those with symptoms may experience: Palpitations, or feelings of a rapid, uncomfortable, irregular heartbeat or a flopping in your chest Low blood pressure Weakness Shortness of breath Chest pain Lightheadedness Confusion Fatigue If you have[bidmc.org]
Somnolence
  • We report a previously healthy 58-years old female, admitted because of nausea, dizziness, somnolence, a left-sided hemiparesis and arterial hypotension. The electrocardiogram showed atrial fibrillation with ST-elevations and ST-depressions.[ncbi.nlm.nih.gov]

Workup

Atrial fibrillations are effectively diagnosed by an accurate medical history and a thorough physical examination. The following diagnostic methods and tests may be implored in patients presenting signs and symptoms of atrial fibrillations:

  • Electrocardiogram (ECG) is considered the primary tool in diagnosing atrial fibrillations. 
  • Holter monitor monitors a 24 hour period of cardiac electrical activity to detect intermittent AF cases.
  • Event recorder will record cardiac activities in a period of weeks to months. It comes with an access button that the patient could easily press during an event or period of chest discomfort or irregularity for real time recording of the dysrhythmia. 
  • Echocardiography elucidates the heart structures and clot formations during atrial fibrillation events [9].
  • Blood tests will determine the presence of electrolyte imbalance and hormonal hyperactivity like hyperthyroidism that can cause clinical dysrhythmias like AF.
  • Chest radiography will demonstrate other anatomic pathology of the heart, pericardium, and the lungs that may induce atrial fibrillation.
Absent A-Waves
  • P waves if arrhythmia is not captured on ECG then Holter monitoring in the outpatient setting these patients are hemodynamically stable telemitry in the inpatient setting Transthoracic echocardiogram (TTE) can assess atrial size and ventricular function[medbullets.com]

Treatment

The general treatment goals involved in the control of atrial fibrillation include the resetting of the heart rate and rhythm, and the active prevention of blood clot formation. Conservative approaches to atrial fibrillation using medications to control rhythm is primarily sought before invasive procedures are implored. Some patients presenting with an organic disease like hyperthyroidism that induces atrial fibrillation may be treated accordingly to relieve the heart of these unnecessary stresses.

To reset the heart to normal rhythm, physicians often resort to cardioversion of the heart which may done by either electrical means (Electrical cardioversion), and by medical cardioversion. When the abnormal rhythm is normalized after electrical cardioversion, patients are often given antiarrhythmic drugs like flecainide, propafenone, dofetilide, and amiodarone to prevent the recurrence of the atrial dysrhythmia. Medications to control resting heart rate may be given like digoxin, beta blockers, and calcium channel blockers although proper precautions must be made to prevent hypotension [10].

In cases, where medical cardioversion fails to achieve its goals, surgical approaches like cardiac catheter ablation, atrio-ventricular node (AV node) ablation, and surgical maze procedures may be the only options left. Patients with atrial fibrillation are at high risk for the development of thrombi and embolus from blood clots; thus, anticoagulation therapy like warfarin, dabigatran, rivaroxaban, and apixaban may be given as a preventive measure.

Prognosis

Atrial fibrillation is closely associated with thromboembolic events that is why patients with AF have up to 1.9 fold risk of death compared to those who don’t suffer from it [6]. Mild asymptomatic AF has a good long term prognosis. The administration of maintenance medications like rate control and anticoagulants does not increase the survival rating of AF patients that are asymptomatic [7].

The risk of a thromboembolic stroke among AF patients beyond 75 years of age is staggering; thus, anticoagulant therapy is perpetually given unless other contraindications are identified. Meta-analysis data revealed that patients who were brought to the emergency room with myocardial infarction presenting with AF have a 40% increase in mortality rate [8].

Etiology

Atrial fibrillation may be induced by any of these conditions:

Epidemiology

In the United States alone, more than 2.2 million Americans are suffering from atrial fibrillation. This cardiac dysfunction is primarily age related, because a fourth of the patients beyond 40 years old are at risk of developing atrial fibrillation in their remaining lifetime [2].

The increasing prevalence of atrial fibrillation among the elderly population is expected to double by 2050 in the US. Atrial fibrillation is relatively rare in infants and childhood, except for those who have undergone prior cardiac surgery [3]. Atrial fibrillation is more common among males than in females, and it is commonly seen in the white race than the black. Patients reaching the seventh decade the prevalence doubles per 10 year increment [4].

Sex distribution
Age distribution

Pathophysiology

Arial fibrillation is strongly associated with cardiovascular diseases like coronary artery diseases (CAD), congestive heart failure (CHF) and diabetes mellitus [5]. Although the exact mechanism is inconclusively elaborated, theories abound that excessive catecholamine, hemodynamic stress and cardiac inflammation causes the AF phenomenon. There are theories of the occurrence of an automatic focus of electrical conduction from sources other than the AV node like some focal regions in the pulmonary vein can cause the unsynchronized impulses that gives rise to AF.

Prevention

The active prevention of heart diseases through a heart friendly diet, exercise, and lifestyle may prevent occurrence of an acquired atrial fibrillation. A healthy lifestyle connotes the willful avoidance of stimulants like caffeine, alcohol and tobacco. Regular exercises and physical activity to maintain ideal body weight is also paramount in the prevention of heart diseases. Patients must understand that severe anger and stress can directly cause heart rhythm dysfunction on a long term basis.

Summary

Atrial fibrillation (AF) is clinically defined as a fast and irregular heart rate that reduces blood flow all over the body. Although atrial fibrillation is not considered life-threatening, persistent symptoms may require immediate treatment to prevent serious complications.

The desynchronized atrial contraction in atrial fibrillation may lead to thrombi or emboli formation that can functionally obstruct blood flow in multiple distant organs and cause ischemia. Atrial fibrillation is often times approached by interventions and medications to normalize the cardiac electrical activities. Atrial fibrillation is classified into three patterns: Paroxysmal AF, persistent AF, and permanent AF [1].

Patient Information

Definition

Atrial fibrillation is clinically defined as a fast and irregular heart rate that reduces blood flow all over the body.

Cause

Atrial fibrillation may be triggered by an ongoing heart disease, metabolic disease, neurologic disorders, and the intake of stimulants.

Symptoms

Patients may be asymptomatic, or may complain of palpitation, dizziness and weakness.

Diagnosis

Electrocardiography, echocardiography, Holter monitoring, blood tests and a chest X-ray may be used to diagnose the condition.

Treatment and follow-up

Medical and electrical cardioversion, and cardiac surgery ablation are the most common treatment options.

References

Article

  1. Fuster V, Rydén LE, Asinger RW, et al. ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology. Circulation. Oct 23 2001; 104(17):2118-50.
  2. Lloyd-Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. Aug 31 2004; 110(9):1042-6.
  3. Abdel Latif A, Messinger-Rapport BJ. Should nursing home residents with atrial fibrillation be ant coagulated? Cleve Clin J Med. Jan 2004; 71(1):40-4.
  4. Rathore SS, Berger AK, Weinfurt KP, Schulman KA, Oetgen WJ, Gersh BJ, et al. Acute myocardial infarction complicated by atrial fibrillation in the elderly: prevalence and outcomes. Circulation. Mar 7 2000; 101(9):969-74.
  5. Kannel WB, Wolf PA, Benjamin EJ, Levy D. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol. Oct 16 1998; 82(8A):2N-9N.
  6. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. Aug 1991; 22(8):983-8.
  7. Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. Dec 5 2002; 347(23):1825-33.
  8. Jabre P, Roger VL, Murad MH, et al. Mortality associated with atrial fibrillation in patients with myocardial infarction: a systematic review and meta-analysis. Circulation. Apr 19 2011; 123(15):1587-93.
  9. Klein AL, Grimm RA, Murray RD, Apperson-Hansen C, Asinger RW, Black IW, et al. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med. May 10 2001; 344(19):1411-20.
  10. Hagens VE, Ranchor AV, Van Sonderen E, Bosker HA, Kamp O, Tijssen JG, et al. Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. Results from the Rate Control Versus Electrical Cardioversion (RACE) Study. J Am Coll Cardiol. Jan 21 2004; 43(2):241-7.

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Last updated: 2018-06-22 03:51