Atrial Fibrillation | Geeky Medics
3/4/15, 7:54 PM
What is Atrial Fibrillation?
Atrial Fibrillation (AF) is the most common cardiac arrhythmia involving the upper
two chambers of the heart (atria). In AF the normal electrical impulses of the sino-atrial
node are overwhelmed by disorganised impulses arising in the atria or pulmonary
veins. This disorganised electrical activity causes uncoordinated contraction of the
atria, resulting in the atria no longer functioning as an effective pump & instead just
quivering. Some of the impulses from the atria sporadicallty pass through the atrioventricular node resulting in irregular contraction of the ventricles, creating the clinical
sign of an irregular pulse. Because the atria are no longer effectively pumping, there is
an increased risk of developing a thrombus within the atria, which has the potential to
pass out of the heart as an embolus and cause a stroke. As a result, atrial fibrillation is a
serious medical condition that should be recognised early and treated to prevent
serious harm or even death of a patient.
Types of Atrial Fibrillation
Paroxysmal AF - episodes of AF that self terminate in under 7 days
Persistent AF recurrent episodes of AF that last more than 7 days
Permanent AF an ongoing long-term episode
Causes
Hypertension
Primary Heart Disease coronary artery disease, valve defects, hypertrophic
cardiomyopathy
Myocardial Infarction
Pneumonia
Excessive alcohol consumption
Hyperthyroidism
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Carbon Monoxide Poisoning
Family History
Signs & Symptoms
Signs
Tachycardia
Irregularly Irregular Pulse
Symptoms
Palpitations
Syncope
Feeling faint
SOB
Chest Pain
Older patients with chronic AF are often asymptomatic
Investigations
Thorough History - onset, duration, associated symptoms (palpitations etc)
Cardiovascular Examination irregularly irregular pulse
ECG - irregular rhythm + absent P-waves
24 Hour ECG Tape - useful to diagnose Paroxysmal AF, which may be missed on
routine ECG
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Bloods - FBC (anaemia), Electrolyte disturbance, Thyroid function (thyrotoxicosis)
Echocardiogram
Looking for left atrial enlargement & structural abnormalities
An echo is indicated when:
Considering the use of rhythm control including electrical or pharmacological
cardioversion
Suspicion of underlying structural heart disease or heart failure
Types of echo:
Trans-thoracic Echo (TTE) first line allows identification of structural
abnormalities
Trans-oesophageal Echo (TOE) - indicated if abnormality detected on TTE or poor
views from TTE
Diagnosis
Atrial fibrillation can be diagnosed on ECG alone with the presence of:
An irregular rhythm
Absent P-waves
The underlying cause however may require further investigations as
mentioned above
Management
The management depends highly on the type of AF the patient is
experiencing
Permanent AF
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Thromboprophylaxis based on stroke risk (CHA2DS2VASc)
Rate control is needed if:
Resting heart rate is >90bpm (110bpm for those with recent-onset AF)
Exercise heart rate is >200bpm minus patients age
1st Line
Beta-blocker
or
Rate-limiting calcium antagonist
2nd Line
If resting heart rate remains >90bpm Beta blocker or Rate-limiting Calcium
Antagonist + Digoxin
If exercise heart rate is the problem Rate limiting Calcium Antagonist + Digoxin
3rd Line
If above treatments still fail to control rate adequately:
Consider Amiodarone
Refer patient to Cardiologist
..
.
Persistent Atrial Fibrillation
Rate or Rhythm Control can be used for Persistent AF
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It depends largely on individual patient factors
Rhythm control is recommended 1st line in patients with persistent AF:
Who are symptomatic
Who are younger
Who are presenting for the first time with lone AF
Whos AF is secondary to a treated or corrected precipitant
Who have congestive heart failure
Rate control is recommended 1st line in patients with persistent AF:
Rhythm Control for Persistent AF
Patient should have follow up at 1 month & 6 months post-cardioversion
This allows assessment of maintenance of sinus rhythm
Rate control for persistent AF is the same as in permanent AF (see above)
.
.
Paroxysmal Atrial Fibrillation
Rhythm control is the preferred management
First appropriate thrombo-prophylaxis should be administered based on
stroke risk
1st line
Flecainide (Pill in the pocket approach) only if patient has all of the
following:
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No LV dysfunction, valvular, or ischaemic heart disease
A history of infrequent symptomatic episodes of paroxysmal AF
A systolic blood pressure of >100mmHg & a resting heart rate >70bpm
An understanding of how & when to take the medication
If pill in the pocket approach not suitable try a standard beta blocker i.e.
Atenolol
.
2nd Line
Depends of the presence or absence of Coronary artery disease (CAD) or LV
dysfunction (LVD)
3rd Line
If the above fails:
Anticoagulation
Its important to assess each individual with atrial fibrillation to determine their risk of
stroke
The CHA2DS2-VASc score is a tool that allows an individuals risk of stroke to be
calculated
This helps inform decisions regarding the need & type of anticoagulation to be used
The maximum score is 9
The table below shows how the CHA2DS2-VASC determines the
anticoagulation choice
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Aspirin
Reduces absolute risk of stroke by 22%
No regular monitoring required as predictable
Very small chance of bleeding (0.8%)
Warfarin
Aim to keep INR between 2-3
Reduces absolute risk of stroke (1-12%) by 64%
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Requires regular monitoring & strict control unpredictable
Increased chance of bleeding over aspirin (1.8% vs 0.8%)
Not safe in those at risk of falls
Good patient education is essential
Dabigatran
Dabigatran is one of the new generation oral anticoagulants.
It is a direct thrombin inhibitor
It is becoming more frequently used as an alternative to Warfarin
The benefit is that it does not require regular monitoring of INR like Warfarin & has
similar efficacy
However there is no way to reverse Dabigatrin in the event of bleeding (unlike
Warfarin)
It is significantly more expensive than Warfarin, even after taking INR monitoring into
consideration
Prognosis
Double the mortality of those without atrial fibrillation
4 to 5 fold higher risk of stroke than those without fibrillation.
Prognosis depends on the patients underlying medical condition.
Any atrial arrhythmia can cause a tachycardia-induced cardiomyopathy
References
1. NICE Guideline. The management of Atrial Fibrillation. June 2006.
2. Eckman MH et al. Moving the tipping point: the decision to anticoagulate patients
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with atrial fibrillation. Circ Cardiovasc Qual Outcomes. 2011 Jan 1;4(1):14-21.
Comments
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