ECG: New onset AF with slow ventricular response

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  • 1. ECG OF THE WEEK Prof.Dr.P.Vijayaraghavan’s unit Dr.C.R.Rajkumar M6 unit
  • 2.
    • 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.
  • 3.  
  • 4. 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
    • .
  • 5. DIAGNOSIS
    • New onset Atrial Fibrillation with slow ventricular response
  • 6. DD FOR AF WITH SLOW VENTRICULAR RESPONSE:
    • High vagal tone
    • AF with associated AV heart block
    • Digoxin effect
    • Beta blocker and other drugs
  • 7. ATRIAL FIBRILLATION
    • The most common sustained cardiac rhythm disturbance
    • Def: Supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of atrial mechanical function.
  • 8. 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
  • 9. 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)
  • 10. MYOCARDIAL AND HEMODYNAMIC CONSEQUENCES
    • 3 factors affect hemodynamic function:
    • loss of synchronous atrial mechanical activity.
    • Irregularity of ventricular response.
    • Inappropriately rapid heart rate
  • 11. 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
  • 12. 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
  • 13. 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.
  • 14. IF UNSTABLE
      • Cardioversion
  • 15. IF STABLE
    • Rate control
    • Minimize thrombo-embolic risk .
    • Establish etiology
    • Restore sinus rhythm
    • Maintain sinus rhythm
  • 16. 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.
  • 17.