{"id":9626,"date":"2021-12-28T17:54:54","date_gmt":"2021-12-28T15:54:54","guid":{"rendered":"https:\/\/meddists.com\/learn\/clinical\/internal-medicine\/cardiology\/atrial-fibrillation-diagnostic-and-treatment\/"},"modified":"2022-01-02T14:53:21","modified_gmt":"2022-01-02T12:53:21","slug":"atrial-fibrillation-diagnostic-and-treatment","status":"publish","type":"page","link":"https:\/\/meddists.com\/learn\/clinical\/internal-medicine\/cardiology\/atrial-fibrillation-diagnostic-and-treatment\/","title":{"rendered":"Atrial fibrillation: diagnostic and treatment"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Atrial fibrillation is an irregularly-irregular supraventricular tachycardia.<\/p>\n\n\n\n<ul class=\"wp-block-list\" id=\"block-0cf297c3-91e8-48a5-ac34-23d9bf88e3cd\"><li>Usually occurs in patients with dilated left atrium (CHF, mitral valve disease) and pulmonary hypertension.<\/li><li>Presents with palpitations, weakness, dyspnea and presyncope on exertion.<\/li><li>AF may be <strong>paroxismal <\/strong>(&lt;7 days) or <strong>persistant<\/strong> (>7 days). Other classifications include:<ul><li><strong>Long-standing AF<\/strong> (>1 year)<\/li><li><strong>Permanent<\/strong> (cannot be converted to sinus rhythm)<\/li><\/ul><\/li><li>The longer the AF lasts, the higher the chance it will becomee permanent.<\/li><li>AF may lead to an intramural thrombus formation and thromboembolization, leading to stroke; anticoagulat therapy is warranted. The risk is especially high in patients with valvular disease.<\/li><\/ul>\n\n\n<span class=\"block-heading\" id=\"header_1\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Pathophysiology<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_1\">\n\n\n<ul class=\"wp-block-list\"><li>Hundreds of action potentials form in the atrium, leading to independent contractions of atrial muscle fibers (400-600BPM).<\/li><li>The actions potentials are sent towards the AV node, and the conduction passes at irregular intervals, leading to irregular QRS complexes and ventricular contraction (75-175BPM).<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">The exact mechanism is unknown, but proposed mechanisms include:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Multiple wavelet mechanism<\/strong>. Different tissue properties (tissue heterogenicity) due to atrial distension lead to re-entry circuits in the left atrium.<\/li><li><strong>Automatic focal activation<\/strong>. A specific focus around the <strong>pulmonary veins<\/strong> forms action potentials that lead to AF.<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_2\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Etiology<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_2\">\n\n\n<ul class=\"wp-block-list\"><li>HTN and CAD<\/li><li>Valvular disease<\/li><li>Cardiomyopathies<\/li><li>Metabolic, electrolyte, and acid-base disturbances (hyperthyroidism)<\/li><li>Alcohol (holiday heart)<\/li><li>Pheochromocytoma and sympethomimmetics<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_3\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Diagnosis<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_3\">\n\n\n<ul class=\"wp-block-list\"><li>Physical examination displays irregularly irregular heart rate and pulse.<\/li><li>ECG displays an irregularly-irregular narrow-complex tachycardia, <strong>lack of P waves<\/strong>, <strong>presence of f waves <\/strong>(fibrillatory), and <strong>absence of an isoelectric baseline<\/strong>.<\/li><li>Echocardiography (preferrably endothoracic) for the visualization of an intramural thrombus.<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_4\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Treatment<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_4\">\n\n\n<ul class=\"wp-block-list\"><li>Immediate DC cardioversion in unstable patients<\/li><li><strong>Ventricular rate control<\/strong><ul><li>Target HR is &lt;110BPM<\/li><li>Use BB (metoprolol), or CCB (if there&#8217;s no CHF)<\/li><\/ul><\/li><li><strong>Rhythm control<\/strong> (cardioversion)<ul><li>DC cardioversion is preferred to pharmaceutical cardioversion (amiodarone, sotalol)<\/li><li>Anticoagulation should be done for at least 3 weeks before and 4 weeks after cardioversion in patients with AF lasting for more than 2 days.<\/li><\/ul><\/li><li><strong>Anticoagulation<\/strong><ul><li>Risk stratification using the CHA2DS2VASc scoring system (see below).<\/li><li>DOACs<\/li><li>In patients with valvular disease and ventricular assist devices, warfarin is the only anticoagulant permitted; keep and INR range of 2-3.<\/li><\/ul><ul><li>Treat warfarin-associated bleeding with FFP or prothrombin complex concentrate.<\/li><\/ul><\/li><li>Catheter ablation<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_5\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">CHA2DS2VASc score<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_5\">\n\n\n<p class=\"wp-block-paragraph\">CHA2DS2VASc score is a scoring system for the risk of stroke in patients with AF.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>It stands for <strong>C<\/strong>HF, <strong>H<\/strong>TN, <strong>A<\/strong>ge >74, <strong>D<\/strong>iabetes, previous <strong>S<\/strong>troke, <strong>V<\/strong>ascular disease, <strong>A<\/strong>ge 65-74, and female <strong>S<\/strong>ex,<\/li><li>Age >74 and previous stroke give 2 points, while the rest give 1 point.<\/li><li>Generally, a score of 1 or more requires anticoagulation.<\/li><\/ul>\n<\/span><div id=\"the_titles\" style=\"display:none;\"><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">Pathophysiology<\/h4><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">Etiology<\/h4><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">Diagnosis<\/h4><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">Treatment<\/h4><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">CHA2DS2VASc score<\/h4><\/div>","protected":false},"excerpt":{"rendered":"<p>Atrial fibrillation is an irregularly-irregular supraventricular tachycardia. Usually occurs in patients with dilated left atrium (CHF, mitral valve disease) and pulmonary hypertension. Presents with palpitations, weakness, dyspnea and presyncope on exertion. AF may be paroxismal (&lt;7 days) or persistant (>7 days). Other classifications include: Long-standing AF (>1 year) Permanent (cannot be converted to sinus rhythm) [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":410,"menu_order":16,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-9626","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.9 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Atrial fibrillation: diagnostic and treatment &#8211; Meddists<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/meddists.com\/learn\/clinical\/internal-medicine\/cardiology\/atrial-fibrillation-diagnostic-and-treatment\/\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"2 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/meddists.com\\\/learn\\\/clinical\\\/internal-medicine\\\/cardiology\\\/atrial-fibrillation-diagnostic-and-treatment\\\/\",\"url\":\"https:\\\/\\\/meddists.com\\\/learn\\\/clinical\\\/internal-medicine\\\/cardiology\\\/atrial-fibrillation-diagnostic-and-treatment\\\/\",\"name\":\"Atrial fibrillation: diagnostic and treatment &#8211; 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