ATRIAL FIBRILLATIONDEFINITION : ABNORMAL HEART RHYTM IN WHICH CHAMBERS OF THE HEART CONTRACT IN DISORGANIZED MANNER, PRODUCING AN IRREGULAR HEART RATE.

ATRIAL FIBRILLATION (AF) IS THE MOST ABUNDANT FORM OF ARRHYTHMIA (> 2.000.000 AF PATIENTS IN US)

INCIDENCE OF AF INCREASING BECAUSE OF AGING POPULATION

AF CAUSES DOUBLING OF MORTALITY AND CONTRIBUTES TO 15% OF STROKES

CAUSED BY IMPULSES WHICH ARE TRANSMITTED TO THE VENTRICLES IN AN IRREGULAR FASHION OR BY SOME IMPULSES FAILING TO BE TRANSMITTED. THIS MAKES THE VENTRICLES BEAT IRREGULARLY, WHICH LEADS TO AN IRREGULAR (AND USUALLY FAST) RHYTM.

UNDERLYING CAUSES : DYSFUNCTION OF SINUS NODE, HEART AND LUNG DISORDERSATRIAL FIBRILATION (2)

ATRIAL FIBRILATION (3)

SYMPTOMSSENSATION OF FEELING HEART BEAT (PALPITATIONS) PULSE MAY FEEL RAPID, RACING, POUNDING, FLUTTERING, OR IT CAN FEEL TOO SLOW PULSE MAY FEEL REGULAR OR IRREGULAR DIZZINESS OR LIGHTHEADEDNESS FAINTING CONFUSION FATIGUE SHORTNESS OF BREATH BREATHING DIFFICULTY, LYING DOWN SENSATION OF TIGHTNESS IN THE CHEST ATRIAL FIBRILATION (4)

CLASSIFICATIONACUTEPAROXISMALCHRONIC

DIAGNOSTIC PROCEDURESECHOCARDIOGRAM NUCLEAR IMAGING TESTS CORONARY ANGIOGRAPHY EXERCISE TREADMILL ECG ELECTROPHYSIOLOGIC STUDY (EP STUDY) ATRIAL FIBRILATION (5)

WHAT RHYTHM IS THIS?EKG AF

EKG AF

ATRIAL FIBRILLATION (6)WHAT ARE THE MANAGEMENT ISSUES?NORMAL VERSUS IMPAIRED HEART.RATE CONTROL.ANTICOAGULATION.CARDIOVERSION (MEDICAL VS. ELECTRICAL).

HOW DO WE TREAT OUR PATIENT?

ATRIAL FIBRILLATION (7)RATE CONTROLLING AGENTSCALCIUM CHANNEL BLOCKERS: - IV DILTIAZEM 0.25 MG/KG (10-15 MG) BOLUS, CAN REPEAT WITH 0.35 MG/KG. - IV VERAPAMIL 5 MG BOLUS Q 15 MIN TO MAXIMUM 30 MG.BETA BLOCKERS: - IV ATENOLOL 5 MG OVER 5 MINUTES, CAN REPEAT TO MAXIMUM 15 MG. 50 MG PO BID IF IV WORKS.DIGOXIN: - IV LOAD 0.5 MG THEN 0.25-.5MG PO OD

ATRIAL FIBRILLATION (8)

ANTICOAGULATION:RECOMMENDATIONS >48 HOURS. (ANTICOAGULATE FIRST)1-3 WEEKS OF ANTICOAGULATION BEFORE AND 4 WEEKS OF ANTICOAGULATION AFTERWARDS.RATE OF THROMBOEMBOLIC EVENTS 0.5-1%

ELECTRICAL CARDIOVERSION:SYNCHRONIZE, START AT 100-200 JOULES (CAN GO UP TO 360 JOULES)REQUIRES CONSCIOUS SEDATIONSAFEST AND QUICKEST METHOD

What can you do if are unsure of the rhythm and think it might be PSVT? ?carotid massage, ?vagal manoeuvres, ?adenosine

-Rate control improves patients discomfort of palpitation and can help cardiac output if compromised.-When to anticoagulate and not to anticoagulate is important because risk of thromboembolic disease is much higher then atrial flutter.-Modality of attempting cardioversion can determine how long patients need to stay in hospital and risks and benefits of each.-Calcium channel blockers 1st line agents: Diltiazem less chance of hypotension and negative inotropic effects, very effective in rate control. Can use infusion 5-10 mg/hr if needed. Verapamil slows rate in 60-70% of patients, may convert to sinus in 10-15%, more peripheral effects ie. hypotension.What can you do if hypotension develops from Ca 2+ blockers? Calcium chloride/gluconate 500-1000mg IV.-Beta blockers; 2nd line agents. IV atenolol reccommended in ACLS, advantage of being able to use oral dose. Propanolol and esmolol also used in practice. Sotalol also used in oral dosing (solely). Cant use in asthmatics, COPD responsive to ventolin, CHF.-Digoxin: not very useful in acute situation, takes 6-11 hrs to take effect. Drug level does not correlate with clinical effects due to large volume of distribution. Will not cause hypotension, some inotropic effects.A Fib controllers: Normal heart beta-blockers, calcium blockers; Impaired heart Digoxin, Diltiazem, Amiodarone. Note Diltiazem can be used in both situations, not too expensive