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Atrial Fibrillation
Diagnosis/Definition
- Atrial fibrillation (AF) is the most common sustained arrhythmia affecting 1.5 million Americans.
- It is characterized by an irregular heart rate and disorganized atrial activity on electrocardiogram (EKG).
- Symptoms can vary considerably. Signs of cardiac decompensation (dyspnea or angina) may be present.
- Many patients will be asymptomatic.
- The sequelae of embolic stroke is the greatest danger of AF.
- Numerous studies have shown the efficacy of anticoagulation therapy in preventing embolic stroke.
Initial Diagnosis and Management
- History addressing hemodynamic consequences of arrhythmia, e.g., syncope, angina, dyspnea.
- History of congestive heart failure (CHF), hypertension (HTN), coronary artery disease (CAD), cerebral vascular accident (CVA) or thromboembolism. Symptoms of associated dz: (alcohol abuse, thyrotoxicosis, etc.).
- 12 lead EKG, PA and LAT CXR, electrolytes, lipids, thyroid function.
- Echocardiogram – valvular disease, left atrial size, LV function.
- Assess for hemodynamic stability, severity of symptoms.
- Address remedial causes (hyperthyroidism, hypoxia, CHF, ischemia, etc.).
- Prevention of thromboembolism: Consider aspirin – patients <70 & no risk factors (CHF, HTN, diabetes, mitral stenosis or prior CVA). Warfarin - mandatory for patients with mitral stenosis and atrial fibrillation. Warfarin preferred - patients with risk factors (CHF, HTN, diabetes, mitral stenosis or prior CVA) or>70 years. If warfarin contraindicated, use aspirin. Consult the Coumadin Clinic for assistance.
- Rate control: Drug of choice dictated by presence of underlying heart disease: digoxin – systolic dysfunction; beta blocker, diltiazem or verapamil – HTN, angina.
- Wolff-Parkinson-White syndrome (WPW) and acute AF – cardioversion or intravenous procainamide.
- The role of cardioversion in stable AF is controversial. The probability of successful restoration of sinus rhythm is low in patients with AF of greater than one year duration, or h/o multiple recurrences despite therapy. Symptoms related to the arrhythmia and risk of anticoagulation also need to be considered.
- Patients with new onset AF are usually offered at least one attempt at cardioversion.
Ongoing Management and Objectives
- With rate control, expect a reduction in symptoms.
- With anti-thrombotic therapy, expect reduction in risk of stroke or embolism.
- With anti-arrhythmic therapy, expect restoration and maintenance of sinus rhythm (though often difficult to maintain).
- Catheter based pulmonary vein modification is an option for some patients as is the surgical Maze procedure (a procedure performed by a surgeon in which linear cuts are made into the atrial wall to block the atrial fibrillation from occurring).
Indications for Specialty Care Referral
Patients with acute AF with cardiac compromise or symptoms due to fast ventricular response should be hospitalized.
Stable patients with AF and significant valvular or structural disease.
Stable patients with AF and disabling symptoms or in whom restoration of sinus rhythm is desired.
Criteria for Return to Primary Care
Patients on stable antiarrhythmic regimens with control of AF.
Patients in chronic AF with adequate rate control and on appropriate anti-thrombotic therapy.
