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ECG: New onset AF with slow ventricular response
 

ECG: New onset AF with slow ventricular response

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    ECG: New onset AF with slow ventricular response ECG: New onset AF with slow ventricular response Presentation Transcript

    • ECG OF THE WEEK Prof.Dr.P.Vijayaraghavan’s unit Dr.C.R.Rajkumar M6 unit
      • 65 year old lady presented with breathlessness to the OPD.
      • No significant past history.
      • On Examination:
        • Pulse was irregularly irregular, varying in volume.
        • Rate – 50/min, Pulse deficit 11/min. BP – 110/70
        • CVS – S1 varying in intensity. No murmurs.
      • ECG was taken.
    •  
    • ECG SHOWS
      • Ventricular Rate of 60/min
      • Varying RR interval
      • QRS Axis 35
      • QRS Duration 100ms
      • QRS morphology normal, occasional artifacts
      • No ST segment T wave changes
      • Absent P waves
      • Undulating baseline
      • .
    • DIAGNOSIS
      • New onset Atrial Fibrillation with slow ventricular response
    • DD FOR AF WITH SLOW VENTRICULAR RESPONSE:
      • High vagal tone
      • AF with associated AV heart block
      • Digoxin effect
      • Beta blocker and other drugs
    • ATRIAL FIBRILLATION
      • The most common sustained cardiac rhythm disturbance
      • Def: Supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of atrial mechanical function.
    • MECHANISM
      • Atrial factors:
      • Enhanced automaticity in 1 or several rapidly depolarizing foci and reentry involving 1 or more circuits.
      • The multiple-wavelet hypothesis: that fractionation of the wave fronts as they propagate through the atria results in self-perpetuating “daughter wavelets
    • CLASSIFICATION:
      • First onset AF: whether or not it is symptomatic or self-limited, recognizing that there can be uncertainty about the duration of the episode and about previous undetected episodes
      • Recurrent AF :
        • (1) Paroxysmal AF (self terminating, episodes <7 days)
        • (2) Persistent AF (not self terminating usually greater than 7 days)
        • (3) Permanent AF (cardio version failed or not attempted)
    • MYOCARDIAL AND HEMODYNAMIC CONSEQUENCES
      • 3 factors affect hemodynamic function:
      • loss of synchronous atrial mechanical activity.
      • Irregularity of ventricular response.
      • Inappropriately rapid heart rate
    • MYOCARDIAL AND HEMODYNAMIC CONSEQUENCES
      • A persistently rapid atrial rate can adversely affect atrial mechanical function (tachycardia-induced atrial cardiomyopathy)
      • A persistently elevated ventricular rate during AF can produce dilated ventricular cardiomyopathy.
      • HF can be the initial manifestation of AF
    • COMMON CAUSES
      • 10% elderly, more than 75 yrs
      • Lone AF less than 65 yrs
      • Valvular heart disease
      • Hypertension
      • Myocarditis and cardiomyopathy
      • Cardiac surgery
      • Hyperthyroidism
      • Alcohol poisoning
      • Autonomic dysfunction
      • SVT
      • Sick sinus syndrome
    • CLINICAL MANIFESTATIONS
      • Symptoms vary with the ventricular rate, underlying functional status, duration of AF and individual patient perceptions.
      • Most patients with AF complain of palpitations, chest pain, dyspnea, fatigue, or light headedness, polyuria, syncope.
    • IF UNSTABLE
        • Cardioversion
    • IF STABLE
      • Rate control
      • Minimize thrombo-embolic risk .
      • Establish etiology
      • Restore sinus rhythm
      • Maintain sinus rhythm
    • PLAN FOR THIS PATIENT:
      • In this patient since clinically it appears to be new onset fibrillation of more than 48 hrs duration, patient can be anti-coagulated. Since clinically stable, rate and rhythm control are of secondary importance.
      • Echo to rule out structural heart disease.
      • TEE (Trans-Esophageal Echo) for LA clot.
    •