ATRIAL

Present by: FIBRILATION

NURHIDAYAH C11111120
Case Report

SUPERVISOR:
Prof dr. Peter Kabo, PhD, Sp FK, Sp
JP (K) , FIHA, FASCC
Patient Identity
 Name : Mrs. S
 Gender : Female
 Age : 57 years old
 Dmission Date : 6-11-2017
 MR : 565234
 HISTORY TAKING

 Chief Complaint : Shortness of breath

• Felt since2 day before admitted to hospital and worsen approx. 2 hours
before being admitted to emergency room. Experienced while Activity.
Ortopnue (+), PND (+),
• chest pain (+/-)
• Asthma (+)
• Nause (-)
• Cough (-)
• Swelling extremities/edemas (-)
• Patient was diagnosed with CAD since 2012
 Past Medical History

 History of hypertension (+) uncontrolled

 History of shoetness of breath (+) since 1 month ago,
after doing hard activity
 History of diabetes (-)
 History of smoking (-)
 History of concumption of alcohol (-)
• History of Swelling extremities/edemas (-)
Family History

 History of cardiovascular disesease in family (-)

 History of family members with same illness (-)
General Status
 Moderate illness/ Well nourished/ Conscious
 Nutritional Status: Normal
 Weight : 57 kg
 Height : 173 cm
 BMI : 18.3 kg/m2

Vital Sign

 Blood Pressure : 150/90 mmHg

 Pulse Rate : 78 bpm
 Respiratory Rate : 32 bpm
 Temperature : 36.6 0C (axilla)
PHYSICAL EXAMINATION

Head and Neck Examinations

Eye : Conjunctiva anemic (-/-), Sclera icteric (-/-)
Lip : Cyanosis (-)
Neck : JVP R +1 cmH₂O

Chest Examination
Inspection : Symmetric between left and right chest.
Palpation : No mass, no tenderness.
Percussion : Sonor between left and right chest, lung-liver
border is ICS VI right anterior.
Auscultation: Respiratory sound : Vesicular
Additional sound :Ronchi +/+ basal bilateral,Wheezing +/+
 •Inspection : unvisible ictus cordis
•Palpation : thrill (+), palpable ictus cordis
•Percussion :
•Superior : ICS II sinistra
Heart •Dextra : ICS IV linea parasternalis dekstra
•Sinistra : ICS V linea axilaris anterior sinistra
•Inferior : ICS VI linea axilaris anterior sinistra
• Auscultation :
•Heart sound : S1, S2 regular, murmur (-)

• Inspection : Distended, follows breathing movement

• Auscultation : Peristaltic sound (+), normal
Abdoment • Palpation : No mass, no tenderness, liver and
spleen unpalpable
• Percussion : Tympani (+)

Extremity • Dorsal pedis edema -/-

• Pretibial edema -/-
ECG interpretation
 Rhythm :
supraventricular rhytm,
irreguler
 Heart rate : 70 bpm
 Axis : Normoaxis
 P wave : hard to
examine
 PR interval : hard to
examine
 QRS complex : duration
0,8s
 T wave : T inverted at
lead II, III, Avf, V1-V6
Test Result Normal value Test Result Normal value

WBC 7.0 x 103/uL 4.0 – 10.0 x 103 Ureum 13 10-50

RBC 4.49 x 106/uL 4.0 – 6.0 x 106 Kreatinin 0,77 0,5-1,2

HGB 14.1 g/dL 12 – 16 PT 10.1 10-14

HCT 42% 37 – 48 APTT 21.6 22.0-30.0

PLT 271x 103/uL 150 – 400 x 103 INR 0,94 -

GDS 178 mg/dL <140 Na 146 136-145

SGOT 20 <38 K 3,4 3,5-5,1

SGPT 15 <41 CL 114 97-111

Radiology Finding
 Dilatation and
elongation aorta
 Cardiomegaly
 Left Pleural effusion
 Working Diagnosis

Atrial Fibrillation Normoventricular Response

Asthma Bronchial
Hypertension Grade II
Coronary Arterial Disease
 MANAGEMENT
Bed rest
Oxygen 2-4 l/min. via nasal canule
IVFD NaCl 0.9% 500 cc/24 hour
Combivent 1 amp/8hours/inhalation
Amlodipine 10mg/24hours/oral
Digoxin 0,25 mg/24hours/oral
Aspilet 80mg/24jhours/oral
Simarc 2mg/24hours/oral
DISCUSSION
Atrial Fibrillation
Atrial fibrillation

A type of supraventricular
tachyarrhythmia with uncoordinated
atrial activation and consequently
ineffective atrial contraction

 The most common arrhythmia

 Chaotic signal
passing through Av
node

Rapid ventclar impuls

incidence
 Most common sustained cardiac
arrhythmia
 Incidence and prevalence increases with
age
 The incidence : <0,5 %below 50 yo, 2% in
age 60-69 yo, 4.6% in age 70-79 yo, 8.8% in
age 80-89 yo
 Men > women
Aetiology
 Rheumatic heart  Thyrotoxicosis
disease  Infection
 Coronary heart disease  Alcohol abuse
(MI)  Pulmonary embolism
 Hypertension
 Myopericarditis
 Hypertrophic
cardiomyopathy
 Cardiac surgery
Pathofisiology
 Focal Activation
 Multiple Wavelets
Classification
1. First Diagnosed AF
2. Paroxysmal AF
3. Persistent AF
4. Long- standing Persistent AF
5. Permanent AF
Symptoms / Signs
 Breathlessness /  Irregularly irregular
dyspnoea pulse
 Palpitations  Atrial rate
 Syncope / dizziness  300-600bpm

 Chest discomfort  Ventricular rate

depends on degree of
 Stroke / Transient AV block
Ischemic Attack  120-160bpm
 6 x risk of  Peripheral rate
Cerebrovascular slower (pulse deficit)
Accident (CVA)
 2 x risk of death
 18 x risk of CVA if
rheumatic heart
disease
Investigations
 Electrocardiogram (ECG) characteristics include: -irregular
R-R intervals, absence of distinct repeating P waves,
irregular atrial activity

 Laboratory :Thyroid function, kidney and electrolyte

 Transthoracic echocardiogram (TTE)

 Establish baseline
 Identify structural heart disease
 Risk stratification for anti-thrombotic therapy

 Transoesophogeal echocardiography (TOE)

 Further valve assessment
 If TTE inconclusive / difficult
Diagnosis
 Based on:

 ECG
 Presentation
 Response to
treatment
Treatment objectives

 Rhythm / rate control

 Stroke prevention
Treatment strategies
 New / Recent onset  Persistent
 Cardioversion  Cardioversion
 Rhythm control  Rhythm control
 Peri-cardioversion
 Paroxysmal thromboprophylaxis
 Rate control or
cardioversion during  Permanent
paroxysm  Rate control
 Rhythm control if  Thromboprophylaxis
needed
Pharmacological Options
 Class Ic Anti-arrhythmics
 Flecainide / Propafenone
 Rhythm control
 May also be pro-arrhythmic

 Class II Anti-arrhythmics
 Beta-blockers
 Mainly rate control
 Control rate during exercise and at rest
 Generally first choice
 Choice depends on co-morbidities
 Class III Anti-arryhthmics
 Amiodarone / Dronedarone
 Mainly rhythm control
 May be pro-arrhythmic
 Concerns over toxicity

 Class IV Anti-arryhthmics
 Calcium channel blockers (verapamil / diltiazem only)
 Rate control only
 Alternative to beta-blockers if no heart failure

 Digoxin
 Rate control only
 Does not control rate during exercise
 Third choice unless others contra-indicated
Acute AF
Treatment will depend on:

 History of AF
 Time to presentation (<> 24 hours)
 Co-morbidities (CHD, CHF/LVSD etc)
 Likelihood of success (History)
 Rate Vs. Rhythm control

 Rhythm control not feasible or safe

 Beta-blocker
 Verapamil
 Digoxin (CHF)
 Rhythm control if possible and safe
 DC cardioversion (if possible)
 Amiodarone (CHD or CHF/LVSD)
 Flecainide (Paroxysmal AF)
Stroke Risk Assessment
(CHADS2)
 C Chronic Heart Failure (1 point)
 H Hypertension (1 point)
 A Age > 75 years (1 point)
 D Diabetes (1 point)
 S Stroke, TIA or systemic embolisation (2 points)

 Score < 2: low risk, aspirin* or anticoagulant

 Score ≥ 2: high risk, anticoagulant indicated

*Evidence for aspirin is weak

Stroke Risk Assessment
(CHA2DS2VASc)
 Alternative to CHADS2
 C Chronic Heart Failure (1 point)
 H Hypertension (1 point)
 A Age > 75 years (2 points)
 D Diabetes (1 point)
 S Stroke, TIA or systemic embolisation (2 points)
 V vascular disease (1 point)
 A Age 65-74 years (1 point)
 Sc Sex category (1 point if female)

 Score ≥2 = High risk – anticoagulate unless

contraindicated
Conclusions
 AF is a common condition.
 Patients may be unaware of its presence and
are therefore at risk of a stroke
 Effective treatment strategies exist to control
symptoms
 Effective treatment strategies exist to reduce
the risk of stroke
 Patient education and choice are central to
improving the likelihood of treatment success