Atrial fibrillation

Introduction
Atrial-two upper chambers of heart Fibrillate-contract very fast and irregularly ACC/AHA/ESC classify AF into:

*not related to reversible cause of AF Can be more than one form in a patient Atria beat rapidly, chaotically and ineffectively-ventricles responds at irregular interval-irregularly irregular pulse

 Paroxysmal
<7 days (most episodes <24 hrs) Terminate spontaneously

*Lone AF-younger pt without structural heart disease, lower risk of thromboembolism

Persistent
>7 days May require pharmacologic or electrical intervention to terminate First presentation or recurrent paroxysmal AF

Permanent
>1 year either because cardioversion has failed or has not been attempted Goal: rate control and anticoagulation

Pathophysiology
Interaction btwn initiating factors and abnormal tissue substrate that capable of maintaining the arrhythmia. Focal initiators of AF
Rapidly firing ectopic foci

Tissue substrate capable of maintaining AF

Multiple wavelets of excitation

Electrophysiological remodelling
Substantial refractory period shortening which facilitate perpetuation of the arrhythmia

Common causes
risk factors -age, male sex, valvular heart disease, systolic/diastolic dysfunction, hypertension, and diabetes Atrial pressure elevation (causing dilatation)
Valvular dz, systolic/diastolic dysfx, hypertrophic cardiomyopathy, pulmonary embolism, intracardiac thrombi or tumour

Inflammatory and infiltrative process

Pericarditis/myocarditis, amyloidosis, sarcoidosis, age induced atrial fibrosis

Infection Endocrine
Hyperthyroidism, phaechromocytoma

Neurogenic
Stroke, subarachnoid haemorrhage

Atrial ischemia
MI

Drugs
Alcohol, caffeine

Idiopathic (lone afib if less than 60 years old) Familial

Clinical features
90% asymptomatic Palpitations, dyspnoea, fatigue, dizziness, angina (chest pain), presyncope or syncope Physical exam
Irregularly irregular pulse, tachycardic Head and neck: exophthalmos, thyromegaly, elevated JVP, cyanosis, carotid artery bruits Lungs: rales, pleural effusion, wheeze, diminished breath sounds Heart: displaced apex beat, S3, prominent P2 Abdomen: ascites, hepatomegaly Lower limb: edema Neurology: sign of TIA or CVA Prior stroke and hyperreflex suggest hyperthyroid

Differential diagnosis
Atrial Flutter Atrial Tachycardia Atrioventricular Nodal Reentry Tachycardia (AVNRT) Multifocal Atrial Tachycardia Paroxysmal Supraventricular Tachycardia Wolff-Parkinson-White Syndrome

Investigation
12 lead electrocardiogram Holter and Event monitor Stress test Echocardiography (TEE, TTE) CXR Blood test
CBC count- anemia, infection Serum electrolytes and BUN/creatinine - electrolyte disturbances or renal failure Cardiac enzymes - CK and/or troponin level primary or seconday MI BNP CHF TFT Toxicology testing or ethanol level

Management
Treat the primary disorder Goal:
Rate control Rhythm control Minimise risk of thromboembolism Treat underlying disease

 Rate control
beta-blockers (metoprolol, atenolol, propanolol) calcium channel blockers (diltiazem, verapamil), sodium-potasium ATPase inhibitors (digoxin), and class III antiarrhythmic agents such as amiodarone.

Rhythm control
Pharmaco: refer image Non pharmaco: direct current cardioversion, ablation

Prevent thromboembolism
Aspirin or warfarin Based on CHADS2 score

Complications
Stroke Heart failure heart can't pump enough blood to meet the body's needs, because the ventricles are beating very fast and can't completely fill with blood.