ATRIAL FIBRILLATION

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WHAT IS ATRIAL FIBRILLATION?
Atrial fibrillation (AF), also called a-fib, is the most
common cardiac arrhythmia. The hallmarks of AF
are irregular and rapid atrial activity, with an
irregular ventricular response that results in
compromised cardiac hemodynamics. AF is
associated with serious morbidity and increased
mortality risk, even in cases when symptoms are
slight. AF is a risk for congestive heart failure
(CHF), angina, cardiac remodeling, and embolic
stroke
After completing this case study, the reader
should be able to:
Determine therapeutic goals for attaining ventricular rate control
or normal sinus rhythm in patients with heart disease presenting
with recurrent paroxysmal atrial fibrillation.
Describe the difference between recurrent paroxysmal and
persistent atrial fibrillation.
Understand the influence of obstructive sleep apnea on the
recurrence and risk of incident atrial fibrillation.
Recognize the importance of identifying and alleviating sleep
disordered breathing in patients with atrial fibrillation,
hypertension and obstructive sleep apnea.

PATIENT PRESENTATION
Chief Complaint

I feel tired and dizzy during the day,
and my heart feels like it is pumping
too fast.

HPI
Mark Finley is a 53-year-old man who presents to the
Emergent
Care Clinic with heart palpitations and dizziness. He has
a 2-year
history of recurrent paroxysmal atrial fibrillation. He now
has
morning headaches and feels tired throughout the day
despite
sleeping 78 hours each night. At his last visit 6 months
ago he was in normal sinus rhythm. He has gained 6
kg since his last visit. The severity of his dizziness
fluctuates; the dizziness is worst in the morning and
during exercise. He has been seen by his primary
care provider in the Internal Medicine Clinic for many
years for HTN and recurrent paroxysmal atrial
fibrillation.

PMH
HTN (previously well controlled on current antihypertensive
regimen)
Recurrent paroxysmal atrial fibrillation (rate controlled)

FH
Both parents had HTN; father had obstructive sleep apnea and
died
of an early morning stroke at age 52, mother died in MVA at age
63.
He has one brother who has hypertension.

SH
Mr. Finley manages a local grocery store and lives at home with
his
wife. He smoked 1 ppd for 10 years and quit 2 years ago. He
drinks
12 glasses of wine each week.

Meds
Lisinopril 20 mg po daily
Metoprolol 50 mg po twice daily
Amlodipine 10 mg po daily
Hydrochlorothiazide 25 mg po daily
Warfarin 5 mg po daily

All
NKDA

ROS
Headache but no blurred vision, chest pain, or fainting
spells;
complains of being tired during the day; mild SOB; 2+
pitting edema


Physical Examination

Gen
Cooperative overweight man in moderate distress

VS
BP 149/84 (supine), P 118 (irregular), RR 20, T 36.3C; Wt 108.3 kg,
Ht 5'11''

Skin
Cool to touch, normal turgor and color

HEENT
PERRLA, EOMI; funduscopic exam reveals mild arteriolar narrowing but
no hemorrhages, exudates, or papilledema

Neck
Large and supple, no carotid bruits; no lymphadenopathy or
thyromegaly, () JVD

Lungs/Thorax
Inspiratory and expiratory wheezes and rales bilaterally no rhonchi



CV
Tachycardia with irregular rate; normal S1, S2;
(+) S3; no S4

Abd
NT/ND, (+) BS; no organomegaly, () HJR

Genit/Rect
Stool heme ()

MS/Ext
Pulses 1+ weak, full ROM, no clubbing or
cyanosis

Neuro
A & O 3; CN IIXII intact; DTR 2+, negative
Babinski
LAB RESULTS (NON FASTING)
LAB RESULTS NORMAL
Na 140 mEq/L 135 - 147 mEq/L
K 4.2 mEq/L 3.5 - 5.2 mEq/L
Cl 99 mEq/L 95 - 107 mEq/L
CO2 24 mEq/L 23 to 29 mEq/L
BUN 23 mg/dL 7 - 20 mg/dl
SCr 1.3 mg/dL 0.5 - 1.4
Glu 101 mg/dL less than 140 mg/dL
INR 2.7 10 to 14 seconds
Hgb 15.2 g/dL
13.5 - 16.5
Hct 48% 41 - 50 %
Plt 293 x 10^3/mm^3 100,000 to 450,000
WBC 9.1 x 10^3/mm^3 4,500 - 10,000
Polys 71% 50-60%
Bands 2% 3 - 5%
Lymphs 24% 25 - 33%
Monos 3% 3 - 7%
Ca 9.1 mg/dL 8.8 - 10.3 mg/dL
Mg 2.1 mEq/L 1.6 - 2.4 mEq/L
CRP 14.3 mg/L
Normal: < 0.8 mg/L
Low risk: <1.00 mg/L
Average risk: 1.00 - 3.00
mg/L
High risk: >3.00 mg/L
ECG
Atrial fibrillation, ventricular rate 97 bpm, mild LVH

Echo
Evidence of diastolic dysfunction (LVEF 59%, LVEDP 15 mm
Hg)
and moderate left atrial enlargement (5.3 cm). No thrombus seen.

Chest X-Ray
Bilateral basilar infiltrates

Assessment
Recurrent paroxysmal atrial fibrillation: moderately
symptomatic.
Diastolic heart failure: preserved ejection fraction with increased
LVEDP, pulmonary and peripheral edema; start furosemide.
Possible sleep apnea: schedule sleep study during hospitalization.
HTN: maintain meds for blood pressure control.
DRUG LIST DOSAG
E
INDICATION TYPE MOA CONTRAINDICATION
LISINOPRI
L
20 mg
po daily
Hypertension, CHF, acute
myocardial infarction.
Renal complications of
diabetes mellitus
ACE
Inhibitor
It prevents the conversion of angiotensin 1
to angiotensin 2, a potent vasoconstrictor.
This results to vasodilation and decreased
peripheral resistance and suppression of the
renin-angiotensin-aldosterone system.
Anuria. Hypersensitivity to any component
of the drug or other sulfonamide-derived
drugs. History of angioedemb relating to
previous treatment with an ACE inhibitor.
Hereditary or idiopathic angioedema.

METOPROL
OL
50 mg
po twice
daily
for the management of
hypertension, angina
pectoris, cardiac
arrhythmias and
myocardial infarction. It is
also used in the
management of
hyperthyroidism and
migraine.
Beta-
blocker
Exerts mainly beta-1-adrenergic blocking
activity but also blocks beta-2-receptors at
high doses. It reversibly and competitively
combines with beta-1-adrenergic receptors
to block sympathetic nerve impulses,
resulting to decreased myocardial
contractility, heart rate, cardiac output and
myocardial oxygen consumption. These
effects lead to decreased blood pressure and
reversal of cardiac arrhythmias,
consequently preventing myocardial tissue
damage.
Bronchospasm or asthma or history of
obstructive airway disease. Metabolic acidos,
sinus bradycardia or partial heart block.
Heart block of 2nd or 3rd degree, severe
bradycardia, cardiogenic, refractory or
decompensated cardiac failure, acute or
severe bronchospasm and in patients with
systolic blood pressure less than mm Hg and
in those with history of hypersensitivity to
metoprolol or beta blockers.
AMLODIPI
NE
10 mg
po daily
This medication is a
calcium channel blocker,
prescribed for high blood
pressure and chest pain. It
widens blood vessels and
improves blood flow by
not making the heart
pump harder
Calcium-
channel
blocker
inhibits influx of calcium ion across cell
membranes to produce relaxation of
coronary vascular smooth muscle
(dilatation of coronary arteries), decrease
peripheral vascular resistance of smooth
muscle(decrease blood pressure) and
increases myocardial oxygen delivery in
patients with vasospastic angina.
Chronic Difficulty having a Bowel
Movement, Severe Narrowing of the Aortic
Heart Valve, Severely Low Blood Pressure,
Severe Liver Disease
HYDROCH
LOROTHI
AZIDE

25 mg
po daily
In the treatment of edema
associated with heart
failure and with renal and
hepatic disorder, also used
in hypertension
Diuretic adjunctive therapy in edema associated
with congestive heart failure, hepatic
cirrhosis and corticosteroid and estrogen
therapy.

Anuria, renal impairment, and sulfonamide
allergy
WARFARI
N
5 mg po
daily
For the venous thrombosis,
atrial fibrillation with
embolisation, pulmonary
embolisation, and as an
adjuct in the treatment of
coronary occlusion.
Anti-
coagulant
inhibits vitamin K dependent activation of
clotting factors, II, VII, IX and X formed in
the liver. It reduces the ability of blood to
clot.

Blood dyscrasias, recent tendencies
associated with active ulceration or overt
bleeding.