ATRIAL FIBRILLATION THE GRANDFATHER OF ALL ARRYHTHMIAS

1. ATRIAL FIBRILLATION …..Grand father of arrhythmias

5. 2.AUTOMATICITY

6. 3.REENTRY

7. In AF all three play a role

8. In AFL – reentry circuit.

9. WAVELETS

11. Action potential

12. Foci of excitation in AF

14. Decreased threshold for AP depolarization in myocardium other than sinus node.

15. Most of APCs

16. VPCs

17. AT

22. AVNRT

23. Wavelets in AF

24. SPIRAL WAVE Functional rentrant circuit. The centre of reentry is excitable but not activated. Latest model of AF Still not clearly understood

25. What is pacing? DELIVERING THE PULSES Treatment in case of SSS And also to suppress the tachyarryhthmias

26. What is overdrive suppression? OVERDRIVE SUPPRESSION is the phenomenon in which the rate of the pacemaker decides the ryhthm over the underlying other cells.. One which is at a faster rate will be the pacemaker.. Others will not give impulses of their own and are suppressed –overdriven by the pulse of other one.. Normally all other pacemaker cells are overdriven by siuns node. Sometimes SA node may be overdrive n by ectopic foci—tachycardia.

27. ATRIAL FIBRILLATION …..Grand father of arrhythmias

29. WILLIAM HARVEY---auricular fibrillation in animals in 1628.

30. Pulse tracing of a patient with AF---Chauveau and Marey

31. First clinical case of AF after surgery of ovarian tumor –Arthur Cushy in london,1907.

32. Rebellious palpitation ---Jean BaptisteSenae

33. Absence of p waves---Lewis

34. Irregular pulse of AF--- “intermssion of pulsation of heart”--Laennec ‘Ataxia of pulse’– Bouilland ‘Delirium cordis’—Nothnagil ‘PulsusIrregularisPerpetius’--- Hering

36. Why?---management strategy changes.

37. Individualised –h/o, compliance ,other disorders.

38. ACC/AHA/ESC 2006 GUIDELINES

39. ETIOLOGICALLY—

40. NON VALVULAR AF—abs of RHD,MVR,prosthetic valve

41. VALVULAR AF--- presence

42. LONE AF.

43. CLINICALLY

44. FIRST EPISODE

45. TRANSIENT AF/REVERSIBLE AF

46. RECURRENT AF

47. PAROXYSMAL AF

48. PERSISTENT AF

50. 2.absence of heart disease or pulmonary disease

51. 3.non hypertensive

52. 4.no clinical or echocardiographic evidence

53. 20-25% of persistent AF

54. Why imp?

55. Low risk of thromboembolism

56. Can be kept on plain aspirin 81-325 mg daily.

58. RECURRENT AF--- 2 or more episodes occurred.> 30 sec

60. M>W

61. 0.5% prevalence 50-59 yrs,,8.8%--80-89 yrs

62. Increases with age.

63. SAFE STUDY–MEN—7.8% overall,elderly -10.8%

64. West briminghamAF project—HTN—37%,IHD—29%

65. Lifetime risk @ 4o yrs –26% in men ,23% in women—FRAMINGHAM STUDY.

66. Relative risk for death –1.5 in men ,1.9 in women—no age influence.

68. 2.VALVULAR HEART DISEASE

69. 3.CORONARY HEART DISEASE

70. 4.CARDIOMYOPATHY

71. 5.CONGENITAL HEART DISEASE

72. 6. CARDIAC SURGERY

73. 7.ELECTRICAL DISEASE—SINUS NODE DYSFUNCTION,TACHY INDUCED,FAMILIAL

74. 8.PERICARDIAL DISEASES

76. TOXIC SUBSTANCE—ALCOHOL

77. AUTONOMICALLY MEDIATED

78. PULMONARY DISEASE

79. NEUROLOGICAL

81. Several mechanisms were put forward based on etiology.

82. What actually initiates is not known..

84. 2.susceptible substrate

85. 3.triggering foci

86. 4.sustained activity of that trigger

87. 5.reentry circuits electrically

88. 6.structural remodelling

90. REENTRY depends on balance between cellular refractoriness and conduction speed.

91. refractory period decreased,slow conduction---continuous conduction in a potentially reentry zone electrically---LEADING CIRCLE THEORY..

93. Persistent --- electrical remodelling occurred.

94. Permanent ---- cellular remodelling occurred.dobrev.d HERZ 2006 : 31: 108-12 duytschaever--- drugs action after remodelling,cardiac res. 2005 ;67-69 burstein –atrial fibrosis –JACC 2008

96. SVC

97. Vein of marshall

99. >5 to 6

102. Abnormal conduction

104. 50 % cases.

105. HTN– reduced LV compliance ---- LA dilation ---- AF

106. HTN ---- CAD ---- AF -- THROMBO EMBOLISM

107. “ increasing pulse pressure is a strong predictor of subsequent AF”------------------------------ -Crawford

108. More risk of stroke .

109. Given a score of 1.

110. In CAD – Infrequent

111. In Ac MI --- early phase 10- 15 % cases.

112. a marker of poor prognosis earlier ….

114. 60% of binge drinkers regardless of presence of alcoholic cardiomyopathy.

115. Episode of AF after heavy alcohol ingestion ---holiday heart syndrome.

117. Uncommon in < 30 yrs

118. Serum free thyroxine concentration ---independently assosciated with AF.

119. Digoxin alone cannot control the heart rate.

120. B blockers are drug of choice

121. Usually transient.

123. Reversible after cardioversion ,ventricular rate control .

124. 20 % of DCM

125. Mild to moderate --- no change in mortality.

127. Shortening of AP

128. Decreased atrial effective refractory period

130. Prev h/o of AF

131. RCA stenosis

132. B blockers discontinued preoperatively.

134. MR 16 %

135. TR

136. MS with MR --- 52 %

137. In AS with HF

138. If a patient in MS had AF ---- risk of stroke is 3-7 times than that of in NSR .

141. Increased AV CONDUCTION

142. Sinus node disease---sinus arrest

143. HOCM

144. AS

145. Apex pulse deficit

146. BP average of three

148. 2D ECHO

149. HOLTER MONITORING—PAROXYSMAL

150. EXERCISE STRESS TEST- IHD

151. CATHETERISATION –BEFORE ABLATION

152. THYROID FUNCTION TESTS IN ALL.

153. Chest x ray

156. F waves– several independent re entrant wavelets within atria.

157. Fine or coarse

158. May be flat line between R-R complexes

159. AR . 350 -500 bpm

160. VR --- irregularly irregular , conduction of AV NODE.

161. How are QRS complexes/

162. Narrow/broad

163. Broad--- BBB, aberrant conduction ,pre excitation

165. The R-R interval increases ---undualting base line.

166. From MAT ---- coarse waves of AF taken as P waves .

167. P waves do change in MAT ..not so in AF.

168. Regular R-R intervals in AF –

169. implanted ventricular pacemakers.

170. Complete AV dissosciation ---- 60 bpm

171. Complete AV Block ---- 40 bpm

172. Digitalis toxicity

174. Atrial impulse may find the RBBB still refractory..

175. Wide QRS complexes.

176. Complex with a short cycle following long cycle is called ashmann phenomenon.

178. They don’t have refractory period of 0.35 seconds as in AV NODE.

179. So there will be a fast ventricular rate.

180. What is the imp?

181. AV NODAL blocking drugs are contraindicated.

184. Normal is less than 4 cm in adults.

185. Early marker of uncontrolled hypertension.

186. Check for valvular lesions

187. Check for left ventricular end diastolic volumes.

188. Cardiac catheterisation ---- pacemaker implantation

189. Holter monitoring ---- paroxysmal events..

190. stress testing in case of IHD.

192. 2.MULTIFOCAL ATRIAL TACHYCARDIA.

193. 3.ATRIAL PREMATURE COMPLEXES

194. 4.SINUS TACHYCARDIA

195. 5.VENTRICULAR TACHYCARDIA