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What is Atrial fibrillation?
• Atrial fibrillation or AF, is the most
common type of arrhythmia . An
arrhythmia is a problem with the rate or
rhythm of the heartbeat. During an
arrhythmia, the heart can beat too fast, too
slow, or with an irregular rhythm.
• AF occurs if rapid, disorganized electrical signals
cause the heart's two upper chambers—called
the atria—to fibrillate. The term "fibrillate" means
to contract very fast and irregularly.
• In AF, blood pools in the atria. It isn't pumped
completely into the heart's two lower chambers,
called the ventricles. As a result, the heart's
upper and lower chambers don't work together
as they should.
What is Atrial Flutter
• AFL is a heart rhythm disorder that is
similar to the more common A Fib. In AFib,
the heart beats fast and in no regular
pattern or rhythm. With AFL, the heart
beats fast, but in a regular pattern. The
fast, but regular pattern of AFL is what
makes it special. AFL makes a very
distinct "sawtooth" pattern on an
CLASSIFICATION OF ATRIAL FIBRILLATION
• According to its duration Atrial fibrillation is classified into
paroxysmal, persistent or permanent (the three P’s).
• Paroxysmal atrial fibrillation is self-limiting and sinus rhythm
restores spontaneously. Paroxysmal atrial fibrillation lasts for less
than 7 days and does not require intervention to convert to a normal
rhythm such as electrical or chemical cardioversion.
• Persistent atrial fibrillation lasts for greater than 7 days. The term
persistent is used when there is a plan to use a rhythm control
strategy and return the patient to sinus rhythm.
• Permanent atrial fibrillation is present when atrial fibrillation is
present 100% of the time for greater than 7 days and there are no
interventions planned to restore sinus rhythm.
• According to its symptoms Atrial Fibrillation can
be:Symptomatic:in this case patients present the typical
symptoms of this arrhythmia.
• Asymptomatic: in this case patients perceive no
symptoms at all. This implies a very risky condition,
because the patient is not aware of the presence of the
arrhythmia. And indeed, suffering from Atrial Fibrillation
without being aware of its presence means not treating it
- a fact that severely increases the risk of stroke
CLASSIFICATION OF ATRIAL FLUTTER
• Typical Atrial Flutter (Common, or Type I Atrial Flutter)
• Involves the IVC(Idioventricular Rhythm) & tricuspid isthmus in the
reentry circuit. Can be further classified based on the direction of the
• Anticlockwise Reentry. This is the commonest form of atrial flutter
(90% of cases). Retrograde atrial conduction produces:
• Inverted flutter waves in leads II,III, aVF
• Positive flutter waves in V1 – may resemble upright P waves
• Clockwise Reentry. This uncommon variant produces the opposite
• Positive flutter waves in leads II, III, aVF
• Broad, inverted flutter waves in V1
• Atypical Atrial flutter (Uncommon, or
Type II Atrial Flutter)
• Does not fulfil criteria for typical atrial
• Often associated with higher atrial rates
and rhythm instability.
• Less amenable to treatment with ablation.
ETIOLOGY OF ATRIAL FIBRILLATION
• Identifying the cause of atrial fibrillation can not be under
emphasized as the treatment of the cause is frequently necessary to
eliminate atrial fibrillation. The classic mneumonic “PIRATES”
encompasses a vast majority of the causes of atrial fibrillation:
• Pulmonary embolus, pulmonary disease, post-operative, pericarditis
Ischemic heart disease, idiopathic (“lone atrial fibrillation”),
intravenous central line (in right atrium)
Rheumatic valvular disease (specifically mitral stenosis or mitral
Anemia, alcohol (“holiday heart”), advanced age, autonomic tone
(vagally mediated atrial fibrillation)
Thyroid disease (hyperthyroidism)
Elevated blood pressure (hypertension), electrocution
Sleep apnea, sepsis, surgery
• Historically, hypertension was thought to be the
most common cause of atrial fibrillation,
however obstructive sleep apnea is present in
about 40% of atrial fibrillation patients and it is
• ll known that obstructive sleep apnea causes
hypertension. The exact proportion of atrial
fibrillation caused directly from obstructive sleep
apnea remains unclear.
SIGNS AND SYMPTOMS OF
• Atrial fibrillation can cause a variety of
symptoms. Some patients with atrial
fibrillation may have no symptoms at all
and may even be unaware that they have
this problem. In many patients, atrial
fibrillation is only discovered by chance, at
a routine health-check. The common
symptoms of atrial fibrillation are........
• Common signs and symptoms of atrial fibrillation:
• Irregular pulse
• Palpitations or racing irregular heart-beats
• Shortness of breath
• Feeling overtired or lacking energy
• Dizziness or confusion
• Light-headedness or fainting
• Feelings of fear or anxiousness
• Chest discomfort or chest pain
RISK FACTORS OF ATRIAL
• Atrial Fibrillaton is typical of elderly age, but there are
other conditions that can favour its insurgence, like co-
morbidities and risk factors.
- Valvular heart disease
- Hypertensive heart disease
- Ischemic heart disease
- Heart failure
COMPLICATIONS OF ATRIAL FIBRILLATION
• Stroke. In atrial fibrillation, the chaotic rhythm may cause blood to
pool in your heart's upper chambers (atria) and form clots. If a blood
clot forms, it could dislodge from your heart and travel to your brain.
There it might block blood flow, causing a stroke.
• The risk of stroke in atrial fibrillation depends on your age (you have
a higher risk as you age) and on whether you have high blood
pressure, diabetes, a history of heart failure or previous stroke, and
other factors. Certain medications, such as blood thinners, can
greatly lower your risk of stroke or the damage to other organs
caused by blood clots.
• Heart failure. Atrial fibrillation, especially if not controlled, may
weaken the heart and lead to heart failure — a condition in which
your heart can't circulate enough blood to meet your body's needs.
• In many situations atrial fibrillation can be detected by
simply feeling the pulse in your wrist or by a doctor
listening to your heart by with a stethoscope. The
presence of an irregular and often fast heart beat would
suggest that you have may have atrial fibrillation.
However, the diagnosis of atrial fibrillation should always
be confirmed by recording a trace of the electrical
signals from the heart, using a testCALLEDan
electrocardiogram (or simply ECG). It is necessary to
confirm the diagnosis of atrial fibrillation by ECG
because irregular heart-beats can also be present in
other heart conditions (arrhythmias)
In the presence of atrial fibrillation, the ECG will highlight the
absence of P waves, that are replaced by small irregular oscillations,
the so-called f waves.
Furthermore, the interval between one beat and another, known as
the R-R interval, isn't always the same.
ECG IN CASE OF ATRIAL FLUTTER
Narrow complex tachycardia
Regular atrial activity at ~300 Beats per minute.
Flutter waves (“saw-tooth” pattern) best seen in leads
II, III, aVF — may be more easily spotted by turning
the ECG upside down!
Flutter waves in V1 may resemble P waves
Loss of the isoelectric baseline
ECG SAMPLES IN ATRIAL FLUTTER
There are inverted flutter waves
in II, III + aVF at a rate of 300
bpm (one per big square)
There are upright flutter waves
in V1 simulating P waves
There is a 2:1 AV
block resulting in a ventricular
rate of 150 bpm
Note the occasional irregularity,
with a 3:1 cycle seen in V1-3
This is the classic appearance
of anticlockwise flutter.
Atrial Flutter with 2:1 Block
There is a narrow complex
tachycardia at 150 bpm.
There are no visible P waves.
There is a sawtooth baseline in
V1 with flutter waves visible at
Elsewhere, flutter waves are
concealed in the T waves and
The heart rate of 150 bpm
makes this flutter with a 2:1
• Detection of atrial fibrillation may be more difficult in
people who do not have it all the time, where the
irregular heart rhythm comes and goes by itself- this is
known as paroxysmal atrial fibrillation. If you have
paroxysmal atrial fibrillation then it may be necessary to
have the ECG tracing recorded for 24 hours or longer
(sometimes for 7 or 14 days if atrial fibrillation episodes
are rare). This test, oftenCALLED “Holter monitoring” is
done using a small device attached by wires to 4 special
stickers (electrodes) placed on your chest. The device is
easy to carry and is hardly noticeably under clothes.
You do not need to stay in
hospital for this test and can
carry on with most of your usual
daily activities. You will probably
be asked to keep a diary of your
activities and symptoms (if any)
you experience (palpitations,
dizzy spells or chest pains etc)
while wearing the monitor. This
portable ECG device is carried
in your pocket or worn on a belt
or shoulder strap.
During stress testing, you exercise to make your heart work
hard and beat fast while heart tests are done
• Event recorder. This portable ECG device is intended to
monitor your heart activity over a few weeks to a few
months. You activate it only when you experience
symptoms of a fast heart rate.
• When you feel symptoms, you push a button, and an
ECG strip of the preceding few minutes and following
few minutes is recorded. This permits your doctor to
determine your heart rhythm at the time of your
• Echocardiogram. In this noninvasive test, sound waves are used to
produce a video image of your heart. Sound waves are directed at
your heart from a wand-like device (transducer) that's held on your
chest (transthoracic echocardiogram). The sound waves that
bounce off your heart are reflected through your chest wall and
processed electronically to provide video images of your heart in
motion, to detect underlying structural heart disease.
• Doctors may conduct a type of echocardiogram in which they insert
a flexible tube with a transducer attached and guide it down your
throat into your esophagus (transesophageal echocardiography). In
this test, sound waves are used to produce images of your heart,
which may be seen more clearly with this type of echocardiogram.
Doctors may use this test to detect blood clots that may have formed
in your heart.
• Chest X Ray
• A chest x ray This test can show fluid buildup in the
lungs and signs of other AF complications.
• Blood Tests
• Blood tests check the level of thyroid hormone in your
body and the balance of your body's electrolytes.
• Blood Clot Prevention
• People who have AF are at increased risk for stroke. This is
because blood can pool in the heart's upper chambers (the atria),
causing a blood clot to form. If the clot breaks off and travels to the
brain, it can cause a stroke.
• Preventing blood clots from forming is probably the most important
part of treating AF. The benefits of this type of treatment have been
proven in multiple studies.
• Doctors prescribe blood-thinning medicines to prevent blood clots.
These medicines include warfarin (Coumadin®), dabigatran, heparin,
• People taking blood-thinning medicines need regular blood tests to
check how well the medicines are working.
• Rate control is the recommended treatment for most
patients who have AF, even though an abnormal heart
rhythm continues and the heart doesn't work as well as it
should. Most people feel better and can function well if
their heart rates are well-controlled.
• Medicines used to control the heart rate include beta
blockers (for example, metoprolol and atenolol), calcium
channel blockers (diltiazem and verapamil), and digitalis
Resetting your heart's rhythm
• Electrical cardioversion. In this brief procedure, an electrical shock
is delivered to your heart through paddles or patches placed on your
chest. The shock stops your heart's electrical activity momentarily.
When your heart begins again, the hope is that it resumes its normal
rhythm. The procedure is performed during sedation, so you
shouldn't feel the electric shock.
• After electrical cardioversion, your doctor may prescribe anti-
arrhythmic medications to help prevent future episodes of atrial
fibrillation. Medications may include:
• Dofetilide (Tikosyn)
• Propafenone (Rythmol)
• Amiodarone (Cordarone, Pacerone)
CATHETER AND SURGICAL
• Catheter ablation may be used to restore a normal heart rhythm if
medicines or electrical cardioversion don't work. For this procedure,
a wire is inserted through a vein in the leg or arm and threaded to
• Radio wave energy is sent through the wire to destroy abnormal
tissue that may be disrupting the normal flow of electrical signals.
• Sometimes doctors use catheter ablation to destroy the
atrioventricular (AV) node. The AV node is where the heart's
electrical signals pass from the atria to the ventricles (the heart's
lower chambers). This procedure requires your doctor to surgically
implant a device called a PACEMAKER, which helps maintain a
normal heart rhythm.
• Another procedure to restore a normal heart
rhythm is called maze surgery. For this
procedure, the surgeon makes small cuts or
burns in the atria. These cuts or burns prevent
the spread of disorganized electrical signals.
• This procedure requires open-heart surgery, so
it's usually done when a person requires heart
surgery for other reasons, such as forheart valve
disease (which can increase the risk of AF).
How Can Atrial Fibrillation Be Prevented?
• Following a healthy lifestyle and taking steps to lower
your risk for heart disease may help you prevent atrial
fibrillation (AF). These steps include:
• Following a heart healthy diet that's low in saturated
fat, trans fat, and cholesterol. A healthy diet includes a
variety of whole grains, fruits, and vegetables daily.
• Not smoking.
• Being physically active.
• Maintaining a healthy weight.
• If you already have heart disease or other AF risk factors, work with
your doctor to manage your condition. In addition to adopting the
healthy habits above, which can help control heart disease, your
doctor may advise you to:
• Follow the DASH eating plan to help lower your blood pressure.
• Keep your cholesterol and triglycerides at healthy levels with dietary
changes and medicines (if prescribed).
• Limit or avoid alcohol.
• Control your blood sugar level if you have diabetes.
• Get ongoing medical care and take your medicines as prescribed.
The most essential part of a
student’s knowledge is
obtained.....not in the
lecture room but at the
there is lost; the rhythms of
disease are learned by
Its unforeseen occurences
stamp themselves indelibly
in the memory.
OLIVER WENDELL HOLMES,M.D.