atrial Fibrillation the common most Arrhythmia, emergency topic, commonly asked question in final year MBBS exam

1. ATRIAL FIBRILLIATION
BY DR FAIZA AKHLAQUE

3. CLINICAL SCENARIO TO EXPLAIN AFIB
68 years old male patient, who presented to the emergency department with complaints of increasing shortness
of breath, dizziness, and the sensation of his "heart racing. Patient said that his symptoms started abruptly earlier
that day and have steadily become worse. He reports a history of long-standing hypertension, coronary artery
disease, and a recent percutaneous transluminal angioplasty with placement of two stents. Patient also confirmed
about no known drug allergies
Vitals on arrival:
HR: 160 bpm BP:100/50 R/R: 26 oxygen saturations 88% @room air.
On Examination:
Tachypneic, Tachycardic, Febrile
Lungs: Crackles B/L lungs present, no wheeze
CVS: Peripheral pulses are diminished and irregular. Patient's skin is cool but dry
A 12-lead ECG was obtained. It showed a narrow QRS complex tachycardia with an irregularly irregular rhythm

4. A 12-lead ECG was obtained. It showed a narrow QRS complex tachycardia with an irregularly irregular rhythm

5. RISK FACTORS:
MAJOR:
1)Hypertension
2)CAD
3)+VE Family history of Afib
4)Heart failure
5)Congenital heart disease
MINOR:
1)Thyroid issues
2)DM
3)CKD
4)Obesity
5)Lung pathology like COPD
Common Exam MCQ: But AFIB is itself a risk factor for “STROKE”

6. COMMON SIGNS AND SYMPTOMS:
Fatigue, palpitations, chest pain, syncope, dizziness, dyspnea, orthopnea, Sleep apnea
cardiac murmurs (such as aortic or mitral stenosis) ,any evidence of heart failure (pulmonary
rales, S3 gallop, peripheral pulses, and jugular venous distention

7. DIAGNOSIS:
->Mainly by 12 leads ECG
->Holter monitoring for 24 hours
->echocardiogram to diagnose structural heart disease or blood clots in the heart.
->Blood tests to rule out thyroid problems or other substances in your blood that may lead to
atrial fibrillation.
->Chest X-ray to see the condition of lungs and heart. Also to diagnose conditions other than
atrial fibrillation that may explain your signs and symptoms.

8. TREATMENT:
(A) Newly Onset Atrial Fibrillation which is divided into stable and unstable patient.
Stable Patient:(No chest pain, no hypotension, no signs of shock) onset of
symptoms less then 48 hours
either Rate control: Betablockers (e.g Metoprolol) or CCB (verapamil)
or Rhythm control either by Amiodarone if structural heart disease or by flecainide if there is non structural
heart cause of atrial fibrillation after giving heparin
If no Spontaneous conversion into sinus rhythm after sedation, consider electric Cardioversion
sympotoms more then 48 hours
Anticoagulate the patient for 3 weeks pharmacological cardioversion  Again anticoagulated for 4 weeks
 If no Spontaneous conversion into sinus rhythm-> after sedation, consider electric Cardioversion
Unstable Patient:(shortness of breath, chest pain, hypotension): electric Cardioversion

9. B) Chronic Afib:
Stroke risk assessment by CHAADS2VASC and bleeding assessment from anticoagulation in atrial
fibrillation