Atrial Fibrillation/Mitral Stenosis Case File

https://medical-phd.blogspot.com/2021/03/atrial-fibrillationmitral-stenosis-
case.html

Author: Eugene C. Toy, MD, Lawrence M. Ross, MD, PhD, Han Zhang, MD, Cristo
Papasakelariou, MD, FACOG

CASE 13
A 35-year-old Hispanic woman comes to your office tired and complaining of
shortness of breath and fatigue. Her history is unremarkable except for a vague history
of fever and joint pain as a child in Mexico. She notes some recent fatigue and
difficulty sleeping that she attributes to job-related stress. On examination, her heart
rate is 120 beats/min, and the rhythm has no discernible pattern (is irregularly
irregular). Auscultation of the heart indicates a systolic murmur (during left
ventricular ejection of blood) that is harsh in character.

⯈ What is the most likely diagnosis?

⯈ What is the underlying etiology?

ANSWER TO CASE 13:

Atrial Fibrillation/Mitral Stenosis

Summary: A 35-year-old Hispanic woman complains of fatigue. She had fever and
joint pain as a child in Mexico. On examination, her heart rate is 120 beats/min and
irregularly irregular. Cardiac examination shows a harsh systolic murmur.
• Most likely diagnosis: Atrial fibrillation due to left atrial enlargement
• Underlying etiology: Mitral stenosis due to rheumatic heart disease

CLINICAL CORRELATION
This 35-year-old woman most likely has atrial fibrillation with tachycardia that is
irregularly irregular. The electrical impulse originating from the sinoatrial (SA) node
of the right atrium does not depolarize both atria in a regular, orderly manner; instead,
this patient’s atria receive constant electrical stimulation, leading to almost continual
atrial contraction that visually resembles a bag of worms. The irregular character of
the pulse is the result of inconsistent transmission of the electrical impulse to and
through the atrioventricular (AV) node and then onto the two ventricles. One common
cause of atrial fibrillation is left atrial enlargement. In this patient, the history of
childhood fever and joint pain likely is the result of streptococcally caused rheumatic
fever. If untreated, the microorganism can cause inflammation of the mitral valve,
leading to mitral stenosis. After 3-5 years, the mitral stenosis is likely to worsen,
leading to atrial enlargement, fibrillation, and pulmonary edema with intolerance to
physical exertion. Treatment in this patient would focus on decreasing her heart rate
with an agent that acts on the AV node such as digoxin. Oxygen and diuretics would
relieve her pulmonary symptoms. An ultimate goal will be conversion of her cardiac
contractions to a normal sinus rhythm. Anticoagulation is often warranted in the face
of long-term atrial fibrillation because of the likelihood of intracardiac thrombus and
the possibility of emboli after conversion to sinus rhythm, called the “atrial stunning”
effect. Surgical correction of the mitral stenosis is also important.

APPROACH TO:
Cardiac Conduction System

OBJECTIVES
1. Be able to describe the type of tissue that makes up the cardiac conduction system
2. Be able to describe the locations and functions of the SA node, the AV node, the
AV bundle (of His), and the right and left bundle branches
3. Be able to describe the nature of sinus rhythm and the influence of the divisions of
the autonomic nervous system on this rhythm
4. Be able to describe the anatomy of the four cardiac valves

DEFINITIONS
MURMURS: Soft or harsh abnormal heart sounds, often caused by turbulent blood
flow, and described in relation to the phase of the cardiac cycle in which they are
heard
ATRIAL FIBRILLATION: Rapid, uncoordinated muscular twitching of the atrial
wall
TACHYCARDIA: A heart rate of at least 100 beats/min