Atrial Fibrillation (AF)

RapidAFib150 (cropped)[1]

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.

This disease emerges due to the following process: endocrine.

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.

Entire body system
  • Coronary Artery Disease Arial fibrillation is strongly associated with cardiovascular diseases like coronary artery diseases (CAD), congestive heart failure (CHF) and diabetes mellitus. [source] Atrial fibrillation may be induced by any of these conditions: Coronary artery disease (CAD) History of heart surgery Viral endocarditis Sick sinus syndrome Sleep apnea Pneumonia and other lung diseases Stimulants like coffee, tobacco, alcohol and medications [source] Other heart-related risk factors include heart failure, coronary artery disease, cardiomyopathy, and congenital heart disease. [source]
  • Fatigue Documentation of any previous surgical or percutaneous AF ablation procedures Palpitations Fatigue or poor exercise tolerance Presyncope or syncope Generalized weakness, dizziness, fatigue [source] Although up to 90% of AF episodes may not cause symptoms, [47] many patients experience a wide variety of symptoms, including palpitations, dyspnea, fatigue, dizziness, angina, and decompensated heart failure. [source] Palpitations, which are sensations of a racing, uncomfortable, irregular heartbeat or a flip-flopping in your chest Weakness Reduced ability to exercise Fatigue Lightheadedness Dizziness Confusion Shortness of breath Chest pain Atrial fibrillation may [source]
  • Weakness This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. [source] Symptoms Patients may be asymptomatic, or may complain of palpitation, dizziness and weakness[source] Only mild palpitations, chest discomfort, light headedness, dyspnea, and generalized weakness are subjectively felt by the patients. [source]
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neurologic
  • Confusion Palpitations, which are sensations of a racing, uncomfortable, irregular heartbeat or a flip-flopping in your chest Weakness Reduced ability to exercise Fatigue Lightheadedness Dizziness Confusion Shortness of breath Chest pain Atrial fibrillation may [source]
  • Dizziness Documentation of any previous surgical or percutaneous AF ablation procedures Palpitations Fatigue or poor exercise tolerance Presyncope or syncope Generalized weakness, dizziness, fatigue [source] Although up to 90% of AF episodes may not cause symptoms, [47] many patients experience a wide variety of symptoms, including palpitations, dyspnea, fatigue, dizziness, angina, and decompensated heart failure. [source] This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. [source]
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respiratoric
  • Dyspnea Although up to 90% of AF episodes may not cause symptoms, [47] many patients experience a wide variety of symptoms, including palpitations, dyspnea, fatigue, dizziness, angina, and decompensated heart failure. [source] This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. [source] Only mild palpitations, chest discomfort, light headedness, dyspnea, and generalized weakness are subjectively felt by the patients. [source]
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gastrointestinal
cardiovascular
  • Chest Pain Chest pain could signal that you're having a heart attack. [source] If you have chest pain, seek emergency medical assistance immediately. [source] Palpitations, which are sensations of a racing, uncomfortable, irregular heartbeat or a flip-flopping in your chest Weakness Reduced ability to exercise Fatigue Lightheadedness Dizziness Confusion Shortness of breath Chest pain Atrial fibrillation may [source]
  • Heart Disease Regular exercises and physical activity to maintain ideal body weight is also paramount in the prevention of heart diseases[source] Cause Atrial fibrillation may be triggered by an ongoing heart disease, metabolic disease, neurologic disorders, and the intake of stimulants. [source] The active prevention of heart diseases through a heart friendly diet, exercise, and lifestyle may prevent occurrence of an acquired atrial fibrillation. [source]
  • Heart Failure The disease is associated with an increased risk of heart failure, dementia, and stroke. [source] This may progress to swelling of the lower extremities, a manifestation of congestive heart failure[source] Other heart-related risk factors include heart failure, coronary artery disease, cardiomyopathy, and congenital heart disease. [source]
  • Irregular Heart Rhythm The result is a fast and irregular heart rhythm[source]
  • Palpitations Documentation of any previous surgical or percutaneous AF ablation procedures Palpitations Fatigue or poor exercise tolerance Presyncope or syncope Generalized weakness, dizziness, fatigue [source] Although up to 90% of AF episodes may not cause symptoms, [47] many patients experience a wide variety of symptoms, including palpitations, dyspnea, fatigue, dizziness, angina, and decompensated heart failure. [source] This usually presents as palpitations, dyspnea, dizziness, fatigue, and weakness among afflicted patients. [source]
  • Tachycardia In addition, AF can be associated with hemodynamic dysfunction, tachycardia-induced cardiomyopathy, and systemic thromboembolism. [source] It is a type of supraventricular tachycardia[source] If cardiovascularly unstable due to uncontrolled tachycardia, immediate cardioversion is indicated. [source]
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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.

Test Results

Jugular Venous Pressure
Other Test Results

ECG

Rhythm
Other ECG Findings

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].

Complications

  • Atrial Fibrillation Possible causes of atrial fibrillation include: However, some people who have atrial fibrillation don't have any heart defects or damage, a condition called lone atrial fibrillation[source] Those who do have atrial fibrillation symptoms may experience signs and symptoms such as: If you have any symptoms of atrial fibrillation, make an appointment with your doctor. [source] Atrial flutter is similar to atrial fibrillation, but the rhythm in your atria is more organized and less chaotic than the abnormal patterns common with atrial fibrillation[source]
  • Atrial Flutter For example, strokes are also a concern in someone with atrial flutter[source] Sometimes you may have atrial flutter that develops into atrial fibrillation and vice versa. [source] As with atrial fibrillation, atrial flutter is usually not life-threatening when it's properly treated. [source]
  • Cardiomyopathy In addition, AF can be associated with hemodynamic dysfunction, tachycardia-induced cardiomyopathy, and systemic thromboembolism. [source] Four types of genetic disorder are associated with atrial fibrillation: Familial AF as a monogenic disease Familial AF presenting in the setting of another inherited cardiac disease (hypertrophic cardiomyopathy, dilated cardiomyopathy, familial amyloidosis [source] Other heart-related risk factors include heart failure, coronary artery disease, cardiomyopathy, and congenital heart disease. [source]
  • Rheumatic Heart Disease ., due to rheumatic heart disease or mitral valve prolapse), mitral regurgitation, left atrial enlargement, hypertrophic cardiomyopathy (HCM), pericarditis, congenital heart disease, and previous heart surgery. [source]
  • Stroke There it might block blood flow, causing a stroke[source] For example, strokes are also a concern in someone with atrial flutter. [source] Sometimes atrial fibrillation can lead to the following complications: Stroke[source]
  • Syncope Documentation of any previous surgical or percutaneous AF ablation procedures Palpitations Fatigue or poor exercise tolerance Presyncope or syncope Generalized weakness, dizziness, fatigue [source]
  • Transient Ischemic Attack Emboli in the brain may result in an ischemic stroke or a transient ischemic attack (TIA). [source] The arrhythmia is sometimes only identified with the onset of a stroke or a transient ischemic attack (TIA). [source] After a transient ischemic attack or stroke about 11% are found to have a new diagnosis of atrial fibrillation. [source]
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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.

Self-assessment

References

  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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  • And Surgical Ablation of Atrial Fibrillation Developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia - H Calkins, J Brugada, DL Packer, R Cappato - , 2007 - Eur Heart Rhythm Assoc
  • A focal source of atrial fibrillation treated by discrete radiofrequency ablation - P Jais, M Haissaguerre, DC Shah, S Chouairi - Circulation, 1997 - Am Heart Assoc
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  • A clinico-pathological study of aorto-iliac thrombosis (the Leriche syndrome) - AJ Gunning, MEJ Hackett, JR Mackenzie, DO Oliver - QJM, 1966 - Oxford Univ Press
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  • Of cardiac arrhythmias: evaluation of the relative roles of abnormal atrioventricular sequencing, irregularity of ventricular rhythm and atrial fibrillation in a canine model - M Naito, D David, EL Michelson, M Schaffenburg - American heart , 1983 - Elsevier
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