Atrial Fibrillation

By DR. Ahmed Abdali

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Atrial Fibrillation AF
is an arrhythmia when the heart beats so slowly or so fast but in an irregular way.

Etiology
here we have CARDIAC CAUSES do to a problem in the heart

so

1- CHF why? because the stretch of the heart is increased.

2- dilated CMP (cardiomyopathy) also the same mechanisms

3- valvular diseases A. mitral stenosis (leads to dilation and the stretch also increased)

B. mitral regurgitation

4- CAD (coronary artery disease) here is ischemia (deceased O2) leads to increase the heart rate

(tachycardia) hypertrophy of the heart

and dilation of the atriums and here again stretch is increased

5- rheumatic heart disease (inflammation)

6- HTN hypertension leads to LVH and leads to dilation of the atria and dilation happens and also stretch

is increased

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NON-CARDIAC CAUSES

1- COPD, pneumonia, acute onset of pulmonary embolism

2- thyrotoxicosis (thyroidism) leads to increased Bets 1 adrenergic which leads sympathetic

nervous system stimulation (SNS)

3 Alcohol (holiday heart syndrome)

4- pheochromcytoma (mechanism related to epinephrine and norepinephrine there lead to stimulate

SNS

5- Cocaine/ methamphetamines (here they act as a sympathomimetic they bind on

epinephrine/norepinephrine

receptors which leads to stimulate SNS

6- Sepsis

7- Surgery (post-operative stress increases stimulation of SNS and catecholamine response)

8- Electrolyte abnormalities

PATHOGENESIS
all these are about the ectopic foci

involve an interaction between initiating triggers, often in the form of rapidly firing ectopic

foci located inside one or more pulmonary veins, and an abnormal atrial tissue substrate capable

of maintaining the arrhythmia.

CHARACTERITIC OF AF
- no P waves

- irregular rhythm

- increased HR or decreased HR

- No symptoms

- palpitations

- SOB (shortness of breath)

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- fatigue

- syncope

in general, sometimes due to AF with CAD or emboli can migrate to

A. Brain -- CVA

B. Spleen -- splenic infarct

C. Kidney -- renal infarct

D. GIT --Acute mesenteric ischemia

CLASSIFICATION
A. according to hemodynamic (HD)

1. unstable HD AF (Decreased BP, Pulmonary edema, chest pain, mental changes.)

2. stable HD AF

no above issues

B. According to ventricular rate

1, AF with Rapid ventricular rate (AF with RVR)

Ventricular HR >>> 100 bpm

2. AF with slow ventricular rate (AF with SVR)

Ventricular HR <60 bpm

C. According to onset and duration

1. New AF: < 48-72 hrs.

2. paroxysmal AF: develops less than 7 days

3. persistent AF: more than 7 days

4. Long standing AF: more 1 year

5. permanent AF: more than 7 days without attempts cardioverter to patient (sinus rhythm)

D. according to mitral valve involvement

1. valvular AF: any evidence of mitral stenosis or mechanical valve or regurgitation

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2. non-valvular AF no mitral valve involvement or mechanical valve or regurgitation

DIAGNOSIS OF AF

A. ECG

we can see

-no P wave

-irregular rhythm

-Rapid HR or Slow HR

but we should also role out

- wolf Parkinson’s white syndrome

- LVH

B. Chest X-RAY

- COPD

- pneumonia

- cardiomegaly

C. TEE (transthoracic echocardiography)

we see

- atrial thrombus (if present we should start with anticoagulants)

- mitral disorders

- LV EF?

- LVH?

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- Atrial size (dilation?)

LABS (looking for the reasons)

-BNP may be elevated in CHF

-troponin maybe elevated in case MI

-CBC maybe WBC elevated in Pneumonia

-TSH reflux maybe elevated due to hyperthyroidism

-blood alcohol level +++

-urine metanephrines ++ in pheochromcytoma

-urine toxicity screen for cocaine/methamphetamine

TREATMENT
A. RATE CONTROL

1. beta blocker like metoprolol

2. CCB (calcium channel blocker) like diltiazem

3. Digoxin (good for those who have HTN/HF)

4. Amiodarone

B. RHYTHM CONTROL

1. Drugs

2. chemical cardioversion (Type 1a - procainamide-) (Type 1c - flecainide-)

3. electrical cardioversion (propafenone class 1c) (Type 3- Ibutilide, amiodarone, etc.)

4. radiofrequency ablation near to pulmonary vein entrances but can lead to

prolongation of QT interval - risk for torsade de point

5. surgery

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