Atrial Fibrillation

M. Haseeb Tariq

Presentation Outline

Definition Normal Rhythm Mechanism What happens in AF Classification Causes Sign & Symptoms Diagnosis Pathophysiology Management
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DEFINITION
Atrial fibrillation describes an irregular and often rapid heart rhythm resulting from abnormal electrical impulses in the heart.

Normal Rhythm Mechanism

Electrical Impulses generated in SA Node (Pacemaker) As the impulse travels through the atrium, it produces a wave of muscle contractions. This causes the atria to contract. The impulse reaches the AV node in the muscle wall between the 2 ventricles. There, it pauses, giving blood from the atria time to enter the ventricles. 4

Normal Rhythm Mechanism

The impulse then continues into the ventricles, causing ventricular contraction that pushes the blood out of the heart, completing a single heartbeat.

In a person with a normal heart rate and rhythm the heart beats 50-100 times per minute.
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What Happens in AF
Multiple impulses travel through the atria at the same time Normal electrical impulses generated by SA node are overwhelmed by disorganized electrical impulses that originate in the atria. The atria may contract at a rate of 400-600 per minute.
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What Happens in AF

These irregular impulses reach the AV node in rapid succession, but not all of them make it past the AV node. Therefore, the ventricles beat slower, often at rates of 110180 beats per minute in an irregular rhythm. The resulting rapid, irregular heartbeat causes an irregular pulse and sometimes a sensation of fluttering in the chest.
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CLASSIFICATION
1st

Detected AF Paroxysmal AF Persistent AF Permanent AF

st 1

Detected AF

All atrial fibrillation patients are initially in the category called first detected AF. These patients may or may not have had previous undetected episodes.

Paroxysmal AF

If a first detected episode self-terminates in less than 7 days and then another episode begins later on, the case has moved into the category of Paroxysmal AF. Although patients in this category have episodes lasting up to 7 days, in most cases of paroxysmal AF the episodes will selfterminate in less than 24 hours
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Persistent AF

If the episode lasts for more than 7 days, it is unlikely to self-terminate, and it is called Persistent AF. In this case, the episode termination may need cardioversion.
Cardioversion is a medical procedure by which an abnormally fast heart rate or cardiac arrhythmia is converted to a normal rhythm, using electricity or drugs.

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Permanent AF

If cardioversion is unsuccessful or it is not attempted, and the episode is ongoing for a long time (e.g. a year or more), the patient's AF is called Permanent AF.

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CAUSES

Primary mostly occurs in younger people (Lone AF)

Hyperthyroidism Alcohol use Pulmonary embolism Pneumonia

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CAUSES

Secondary
Heart valve disease left ventricular hypertrophy Coronary heart disease Cardiomyopathy Pericarditis

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Signs & Symptoms

Symptoms related to a rapid heart rate

Palpitations Exercise intolerance Occasionally produce angina Dyspnea Edema

Secondary AF
Angina Weight loss Diarrhea

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Diagnosis

Determination of the etiology Classification History Physical examination ECG

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ECG Changes in AF

Absence of P waves Irregular R-R intervals Wide QRS complexes

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PATHOPHYSIOLOGY
Progressive fibrosis of the atria primarily due to atrial dilation, genetic causes and inflammation.

Dilation of the atria (due to any structural abnormality causing a rise in the intra-cardiac pressures including valvular heart disease, hypertension and CHF). Activation of the renin aldosterone angiotensin system (RAAS). Subsequent increase in matrix metaloproteinases and disintegrin. Atrial remodeling and fibrosis, with loss of atrial muscle mass.

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MANAGMENT
The main goals of treatment are to prevent Circulatory instability Rate or rhythm control Stroke anticoagulation If Cardoivascularly Unstable Cardioversion
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Anticoagulation

It including the use of

Aspirin Heparin Warfarin

Depending on cost, risk of stroke, risk of falls, compliance, and speed of desired onset of anticoagulation.
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Rate Control

Achieved with medications that work by increasing the degree of block at the level of the AV node. Beta blockers (cardioselective beta blockers)
Metoprolol Atenolol Bisoprolol Nebivolol Verapamil

Non-Pihydropyridine CCBs
Diltiazem

Cardiac glycosides
Digoxin
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Cardioversion

It is a noninvasive conversion of an irregular heartbeat to a normal heartbeat using electrical or chemical means Electrical Cardioversion Restoration of normal
heart rhythm through the application of a DC electrical shock.

Chemical Cardioversion Performed with drugs,

Amiodarone Procainamide Ibutilide Flecainide
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Dronedarone Dofetilide Propafenone

Questions??