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UCLA Family Medicine Department

IMG Program
Carlos Yoo

A 66 year-old man comes to the


emergency department complaining of
a several-day history of an intermittent
sensation of fluttering in the chest. He
feels weak when the episodes occur but
denies chest pain or shortness of breath.
He has had hypertension for 20 years,
controlled well with enalapril, and he
takes albuterol for asthma. He denies
any alcohol use.
UCLA Family Medicine Department IMG Program Carlos Yoo

VS: Temperature 36.8C (98.3F), Blood


pressure 140/80, pulse 140/min, respirations
12/min
PE: supple neck, no jugular vein distension
or thyromegaly.
CV: irregularly irregular rhythm with no rubs
or gallops.
Chest: clear sounds
Abd: Benign
Extremities: no edema
UCLA Family Medicine Department IMG Program Carlos Yoo

Atrial Fibrillation
Multifocal atrial tachycardia
Supraventricular tachycardia
Pulmonary Embolism
Thyrotoxicosis

UCLA Family Medicine Department IMG Program Carlos Yoo

EKG
Thyroid Function tests
Cardiac enzymes
Echocardiogram
ABGA

Within Normal limits


Normal
Normal Ejection fraction, left atrial
enlargement
Within Normal limits

UCLA Family Medicine Department IMG Program Carlos Yoo

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

GOALS
Hemodynamic stabilization
Ventricular rate control

Prevention of embolic complication

UCLA Family Medicine Department IMG Program Carlos Yoo

Patient with diagnosis of atrial fibrillation


Hemodynamically
stable
Yes

No
Unstable
Hypotension
Confusion
Cardioversion
Angina
.

Control ventricular rate:


Diltiazem
Beta Blockers
Calcium Channel blockers
Digoxin
Long standing HTN
Amiodarone
Ischemic heart dz
Spontaneous conversion to sinusCHF
rhythm
Hyperthyroidism
PE
Yes
No
Lung ca
Alcohol
Hypothermia
Assess cause of
Contraindication to cardioversion?
Electrolytes
atrial fibrillation
imbalance
Etc. .
Cont

Cont

Yes

No

Cardiversion
Start Heparin IV

Warfarin
Consider
long-term
anticoagulation

Yes

Aspirin

<48hs

Immediate
medical or
Long
standing HTN
electrical
Ischemic heart dz
cardioversion
CHF
Hyperthyroidism
Atrial fibrillation persist?
PE
Lung ca
No
Alcohol
Hypothermia
Assess cause of atrial
Electrolytes
fibrillation
imbalance
Etc. .

>48hs
Later elective
cardioversion
after 3weeks of
warfarin
Early TEEguided
cardioversion

UCLA Family Medicine Department IMG Program Carlos Yoo

http://www.chestjournal.org/content/13
5/3/849.full.html
http://www.aafp.org/afp/20020715/249.
html
http://www.aafp.org/afp/20020715/261.
html
http://www.americanheart.org/downloa
dable/heart/222_ja20017993p_1.pdf

UCLA Family Medicine Department IMG Program Carlos Yoo