Case Report

ATRIAL FIBRILLATION
Department of Cardiology Faculty of Medicine
Syiah Kuala University, Aceh, Indonesia
March, 2015

Presented: Supervisor:
Maryamah dr. Hj. Sri Murdiati, Sp. JP (K) - FIHA
 Background

• Atrial fibrillation is the most common sustained

arrhythmia
• Affects 2 million Americans
• 6% over the age of 65 experience it
• Responsible for 15% strokes

European Society of Cardiology. Guidelines for the management of atrial fibrillation. European Heart Journal. 2010. 31.
p.2369–2429.
 6%
PSVT
Atrial fibrillation
accounts for 1/3 of 6%
PVCs 18%
all patient Unspecified
4%
discharges Atrial
with arrhythmia as Flutter
principal diagnosis.
9% 34%
SSS Atrial
Fibrillation

8%
Conduction
Disease
10% VT
3% SCD

2%VF

Data source: Baily D. J Am Coll Cardiol. 1992;19(3):41A.

Conditions predisposing to, or
encouraging progression of AF
Types of Atrial Fibrillation
 Clinical Evaluation
• Acute ventricular rate control
• Immediate assessment of the need for anticoagulation
• First decision to add rhythm control therapy to
management based on symptoms (may be reassessed
later)
• Treatment of underlying heart disease
 Elderly patient
Palpitation
Fatigue/weakness
Long term hypertension
Tachycardia
Irregularly irregular rhythm
EKG: atrial fibrillation waves, inconsistent R-R
intervals, absence P waves.

ATRIAL FIBRILLATION

UCLA Family Medicine Department IMG Program Carlos Yoo

 Patient with diagnosis of atrial fibrillation

Hemodynamically
stable
Yes No
Unstable…
•Hypotension
Control ventricular rate: •Confusion
Cardioversion
Diltiazem •Angina
•Beta Blockers •….
•Calcium Channel
blockers
•Digoxin Long standing HTN
•Amiodarone Ischemic heart dz
Spontaneous conversion to sinusCHF
rhythm
Hyperthyroidism
Yes PE No
Lung ca
Alcohol
Assess cause of
Contraindication to cardioversion?
Hypothermia
atrial fibrillation Electrolytes imbalance
Etc. .
Cont’
 Cont’

Yes No

Cardiversion

Start Heparin IV

Consider long-term
Warfarin Aspirin
<48hs >48hs
anticoagulation

•Immediate •Later elective

medical or cardioversion
electrical
Long standing HTN after 3weeks of
cardioversion
Ischemic heart dz warfarin
CHF • Early TEE-
Yes guided
Hyperthyroidism
Atrial fibrillation persist? cardioversion
PE
No Lung ca
Alcohol
Assess cause of atrial Hypothermia
fibrillation Electrolytes imbalance
Etc. .
UCLA Family Medicine Department IMG Program
 Case report
• Name : Mr. ARPT
• ID : 1-04-50-19
• Age : 84 years
• Sex : male
• Religion : moslem
• Address : Pidie
• Date of hospitalized : 20 march 2015
• Date of Examination : 25 march 2015
 History
• Present medical history:
Patient came to hospital with the complaint heart palpitation
and chest pain since 2 days before hospitalisation. Patient also
complaint often obtain tired. It attacked patient while doing his
activities, such as walking a long distance or standing along
and get better when the patient have rested, it’s already
happened for two month and got worse in this week.
• Past Medical history: Patient hadn’t experienced similar
symptoms before, history of HT (+) since 2 years ago, there is
no history of DM and stroke.
• History of Drug uses:
Patient has already taken cardio medications since 2 years
ago, there are:
amlodipine 10 mg,
captopril 12,5 mg,
omeprazole
• Family history:
There is no one of patient’s family has the same
complaint like patient. History of HT and DM in
family (-)
 Vital Sign

Compos 150/60 22 times in

112 bpm
Mentis mmHg minute
 Physical Examinations
• Head : normocephali
• Eyes : konjungtiva pale (-/-), icterik of sclera (-/-)
• Ear : normotia, cerumen (-/-)
• Nose : cerumen (-)
• Mouth : cianosis (-)
• Neck : JVP R-2 cmH2O
• Thorax :
Inspection : symmetric, retrracsion of epigastrium (-)
Palpation : pain (-), right SF = SF
Perkution : sonor (+/+)
Auscultation : ves (+/+), crackless(-/-) , wh (-/-)
• Cor :
Inspektion : Ictus cordis is not palpable
Palpation : Ictus cordis not palpable
Auskultasi : cor sound I>II, irregular (+),
• Abdomen :
Inspection : symmetric, distention (-)
Palpation : soepel, pain (-), hepar/lien/renal not palpable
Percution : tympanic
Auscultation : peristaltic(+) N,
Extremitas : oedem (-), cianosis (-)
 EKG 20 Maret 2015

Rhythm : Atrial Firilasi RVR

ST elevation : negatif
Axis : normoaksis
ST depretion : negative
P wave : difficult to asses
Conc : Atrial Fibrilasi
Interva of l P-R : difficult to asses
RVR
QRS rate : 132 bpm
 EKG tanggal 21 Maret 2015

rhythm : Atrial Firilasi NVR

ST elevation : negatif
Axis : normoaksis
ST depretion : negative
P wave : difficult to asses
Conc : Atrial Fibrilasi
Interva of l P-R : difficult to asses
NVR
QRS rate : 89 bpm
 Rontgen thoraks

Cor : normal size

and shape, but there is
calsification in aortic
knob
Pulmo : normal
Both of phrenicocostalis
sinus are sharp

Conc: Aortosclerosis

Echo 18 march 2015: Diastolik disfunction

 DIAGNOSES
1. Atrial Fibrilation
2. Hypertention stage II
3. Aypical chest pain ec dd/ 1.dyspepsia
2. APS
4. Dyastolic disfunction
 Planning

• Serial ECG
• laboratory (profile of lipid, ureum, creatinin,
electrolit)
• Echocardiografi
 Treatments
March 20th 2015
• IVFD RL 10 gtt/menit
• Inj. Digoxin 1 amp (ekstra)
• Inj. Ranitidin 1 amp/12 h
• Simarc (warfarin) 1x2mg (night)
• Diovan 1x80 mg
March21st 2015
• Heart palpitation is reduce
• Changed Inj. Digoxin to Digoxin 1x1 tab
• Inj Lasix 1 amp/12 h
March 23rd 2015
• Digoxin stop
• Simarc stop
• V-Block ½ tab (morning)
March 26th 2015: Home recipes
• diovan 1x80 mg
• lasix 1x1 tablet
 Prognosis

• Quo ad Vitam : Dubia ad bonam

• Quo ad Functionam : Dubia ad malam
• Quo ad Sanactionam : Dubia ad malam
 Case analysis
• Present medical history: Patient came to hospital
with the complaint heart palpitation, chest pain since
2 days before hospitalisation. Generally, symptoms of
AF is increased heart rate, irregular heart rhythm and
hemodynamic instability. AF also provide other
symptoms caused by decrease blood oxygenation,
such dizziness, weakness, fatique, tightness and chest
pain.
• 90% of Af episodes doesn’t give this symptoms.
For this case, patient was treated with Digoxin 1
amp (ekstra), Simarc (warfarin) 2mg (night),
Diovan 1x80 mg, Inj. Ranitidin 1 amp/12 h: the
goal treatment of AF is to restore sinus rhythm
of ventricular rate control and prevention of
thromboembolism and treated hypertension.
THANK YOU