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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.

Coronary Artery Disease
  • The section on concomitant AF and coronary artery disease was developed in collaboration with the CCS Antiplatelet Guidelines Committee. Details of the updated recommendations are presented, along with their background and rationale.[ncbi.nlm.nih.gov]
  • artery disease, acute coronary syndromes, and percutaneous coronary intervention; (6) the rate control target and medications recommended to achieve the target; and (7) the role of "first-line" catheter ablation, open surgical ablation, and left atrial[ncbi.nlm.nih.gov]
  • 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]
Weakness
  • Protective factors were a history of diabetes mellitus (weak association) and the presence of a urinary tract infection (weak association).[ncbi.nlm.nih.gov]
  • 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]
  • CASE REPORT: 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]
  • Furthermore, new aspects of antithrombotic therapy and risk assessment of stroke have been revealed: the efficacy of stroke prevention with aspirin is weak, while the risk of major bleeding is not significantly different from that of oral anticoagulant[ncbi.nlm.nih.gov]
Fatigue
  • Symptoms include irregular pulse, palpitations, shortness of breath and fatigue. Inova offers leading expertise in all aspects of atrial fibrillation management.[inovaheart.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]
  • 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.[icd9data.com]
  • 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]
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]
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 developed pronounced dyspnea on exertion, and repeated ECGs and another Holter monitor now showed persistent AF.[doi.org]
  • 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]
  • Congestive heart failure was defined by clinical symptoms (dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea), physical examination (elevated jugular venous pressure, peripheral edema, weight gain), or pulmonary congestion on chest x-ray[dx.doi.org]
  • Patients most commonly report palpitations, dyspnea, fatigue, lightheadedness, and chest pain.[web.archive.org]
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]
  • While taking anticoagulants, make sure the doctor knows about any planned or existing pregnancy or any signs of bleeding, such as: very large bruises nausea and light-headedness vomiting blood coughing up blood unusually heavy menstrual flow gums that[medicalnewstoday.com]
  • […] nerve injury resulting in diaphragmatic paralysis Shortness of breath, elevated hemidiaphragm None; usually resolves spontaneously Iatrogenic atrial flutter Tachycardia Cardioversion, antiarrhythmic drugs, or repeat ablation Gastric motility disorder Nausea[doi.org]
Heart Failure
  • Patients were followed for up to 7 months, and the end-point was occurrence of heart failure.[ncbi.nlm.nih.gov]
  • […] fibrillation and heart failure.[dx.doi.org]
  • Among the outcomes examined, the highest absolute risk increase was for heart failure. Associations between atrial fibrillation and included outcomes were broadly consistent across subgroups and in sensitivity analyses.[ncbi.nlm.nih.gov]
  • —In addition to intrinsic cardiac causes such as valve disease and congestive heart failure, risk factors for cardiovascular disease also predispose to atrial fibrillation.[dx.doi.org]
Heart Disease
  • The most common conditions associated with AF were hypertension (10.3%-71.9%) and valvular heart disease (5.6%-66.3%). The prevalence of stroke in patients with AF ranged from 6.7% to 27%.[ncbi.nlm.nih.gov]
  • disease, sudden cardiac death, congestive heart failure, chronic kidney disease, and peripheral arterial disease.[ncbi.nlm.nih.gov]
  • 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 most common causes of AF are coronary heart disease, hypertension, valvular heart disease and hyperthyroidism.[patient.info]
Hypertension
  • The most common conditions associated with AF were hypertension (10.3%-71.9%) and valvular heart disease (5.6%-66.3%). The prevalence of stroke in patients with AF ranged from 6.7% to 27%.[ncbi.nlm.nih.gov]
  • DIAGNOSES: This patient was diagnosed with hyperkalemia, hypertension, and AF. INTERVENTIONS: He was treated with an intravenous infusion of calcium gluconate, insulin and dextrose, an oral kayexalate, and emergency hemodialysis.[ncbi.nlm.nih.gov]
  • Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey, 1988–1991. Hypertension . 1995; 25 : 305–313.[dx.doi.org]
  • AF increases the risk of stroke, and anticoagulation should be considered on the basis of stroke risk - clearly indicated with a CHADS 2 score (congestive heart failure, hypertension, age 75 years, diabetes, 1 point each; previous stroke or transient[ncbi.nlm.nih.gov]
  • Obesity-related risk factors, such as hypertension, vascular disease, obstructive sleep apnea and pericardial fat, are thought to result in atrial electro-structural dysfunction.[ncbi.nlm.nih.gov]
Tachycardia
  • The complex structure and special conductive properties of the SVC can result in complicated atrial tachycardia (AT), atrial flutter, or AF.[ncbi.nlm.nih.gov]
  • In the emergency department, atrial fibrillation persisted and he experienced additional episodes of ventricular tachycardia.[ncbi.nlm.nih.gov]
  • Instead of intermittently contracting, the atria quiver continuously in a chaotic pattern, causing a totally irregular, often tachycardia ventricular rate.[icd9data.com]
  • There are three major types of tachycardia: Atrial tachycardia (starting in the atria) Supraventricular tachycardia (starting above the ventricles) Ventricular tachycardia (starting in the ventricles) Bradycardia refers to a slow heart rhythm, caused[columbiasurgery.org]
  • The first patient underwent pulmonary vein isolation (PVI) and the ablation of a concomitant atrioventricular nodal reentrant tachycardia. The second patient was also treated with a PVI and a redo PVI 8 months later.[ncbi.nlm.nih.gov]
Palpitations
  • He correlated gross irregularities (palpitation) with necropsy observation of mitral valve disease and dilatation of the left ventricle.[ncbi.nlm.nih.gov]
  • PATIENT CONCERNS: We report a 47-year-old woman with no previous medical history presented with intermittent palpitation for 3 days. DIAGNOSES: The electrocardiography showed AF with rapid ventricular rate.[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]
  • 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]
Stroke
  • Strokes related to AF are associated with higher mortality, greater disability, longer hospital stays, and lower chance of being discharged home than strokes unrelated to AF.[ncbi.nlm.nih.gov]
  • Risk factors for stroke were assessed by univariate and multivariate analyses. The mean follow-up was 7.4 years. Among these patients, 68 had a stroke during the follow-up (rate of stroke per year of follow-up 3.2%).[ncbi.nlm.nih.gov]
  • Edoxaban is most likely similar to warfarin in preventing stroke or systemic embolism and also most likely has less risk for major bleeding and hemorrhagic stroke than warfarin.[effectivehealthcare.ahrq.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]
  • 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.[icd9data.com]
  • This can cause problems including dizziness, shortness of breath and tiredness.[nhs.uk]
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]
  • 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.[icd9data.com]
  • 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]
  • Symptoms may include: Pulse that feels rapid, racing, pounding, fluttering, irregular, or too slow Sensation of feeling the heart beat ( palpitations ) Confusion Dizziness , lightheadedness Fainting Fatigue Loss of ability to exercise Shortness of breath[nlm.nih.gov]
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.
Atrioventricular Dissociation
  • After establishment of a stable perfused-heart preparation, the posterior atria were cut away to expose the left and right atrial endocardium, and the atrioventricular node was mechanically crushed, resulting in atrioventricular dissociation.[dx.doi.org]
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]
Abnormal ECG
  • At the same time, the harms of diagnostic follow-up and treatment prompted by abnormal ECG results are well established and include misdiagnosis and invasive testing.[ncbi.nlm.nih.gov]
  • But the paper notes that abnormal ECGs were sent to a cardiologist for review, and also says that the Kardia produced some false positives (indications of AFib that the reviewing cardiologists found to be false).[spectrum.ieee.org]

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