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Atrial Fibrillation (AF)

SOURCE

Source: Sanoski CA, Bauman JL. The arrhythmias. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146057036. Accessed April 28, 2017.

DEFINITION

  • Supraventricular arrhythmia characterized by extremely rapid (atrial rate of 400–600 beats/min) and disorganized atrial activation resulting in irregularly irregular pulse (120–180 beats/min)

ETIOLOGY

  • Hypertension.

  • Coronary artery disease.

  • Cardiomyopathy.

  • Pericarditis.

  • Previous heart surgery.

  • Hyperthyroidism.

  • Sleep apnea.

  • Alcohol abuse.

  • Smoking.

  • Excessive caffeine consumption.

PATHOPHYSIOLOGY

  • Predominant mechanism is reentry, usually associated with organic heart disease causing atrial distention (eg, ischemia or infarction, hypertensive heart disease, valvular disorders).

EPIDEMIOLOGY

  • Most common sustained arrhythmia.

  • Prevalence in United States, 0.4–1%; increases with age.

  • Prevalence expected to increase to 12–15 million Americans by 2050

  • Lifetime risk for AF in persons at least 40 years of age estimated to be 1 in 4

CLINICAL PRESENTATION

SIGNS AND SYMPTOMS

  • Symptoms:

    • Rapid heart rate.

    • Palpitations.

    • Worsening symptoms of heart failure (shortness of breath, fatigue)

  • Sign: irregularly irregular pulse.

  • Embolic stroke potential complication of AF

DIAGNOSIS

MEANS OF CONFIRMATION AND DIAGNOSIS

  • Electrocardiogram (ECG) shows irregularly irregular supraventricular rhythm with no discernible, consistent atrial activity (P waves); ventricular response usually 120–180 beats/min.

DIFFERENTIAL DIAGNOSIS

  • Atrial flutter.

  • Atrial tachycardia.

  • Atrioventricular nodal reentry tachycardia (AVNRT)

  • Multifocal atrial tachycardia.

  • Paroxysmal supraventricular tachycardia.

  • Wolff-Parkinson-White syndrome.

DESIRED OUTCOMES

  • Restore sinus rhythm.

  • Prevent thromboembolic complications.

  • Prevent further recurrences.

TREATMENT: GENERAL APPROACH

  • Evaluate need for acute treatment (usually with drugs that slow ventricular rate) (Fig. 1).

  • Consider methods to restore sinus rhythm, considering risks involved (eg, thromboembolism).

  • Consider ways to prevent long-term complications (eg, recurrent arrhythmia, thromboembolism).

FIGURE 1.

Algorithm for the treatment of atrial fibrillation (AF) and atrial flutter. aIf AF is less than 48 hours in duration, anticoagulation prior to cardioversion is unnecessary; initiate anticoagulation with unfractionated heparin, a low-molecular-weight heparin, apixaban, dabigatran, or rivaroxaban as soon as possible either before or after cardioversion for patients at high risk for stroke (this anticoagulant regimen or no antithrombotic therapy may be considered in low-risk patients). bAblation may be considered for patients who fail or do not tolerate at least 1 AAD or as first-line therapy (before AAD therapy) for select patients with recurrent symptomatic paroxysmal AF. cChronic antithrombotic therapy should be considered in all patients with AF and risk factors for stroke regardless of whether or not they remain in sinus rhythm. (AAD, antiarrhythmic drug; AF, atrial fibrillation; AFl, atrial utter; BB, ...

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