A 41-year-old female presented with breathlessness, palpitations, and chest pain for 3 days. She has a history of valvular heart disease surgery 14 years ago. On examination, she was dyspneic, tachycardic, and had pedal edema. ECG showed atrial fibrillation with a rate of 160 beats/minute. Echocardiogram revealed moderate mitral stenosis and mild tricuspid regurgitation with enlarged left atrium and moderate mitral annular calcification. The patient was diagnosed with atrial fibrillation likely due to rheumatic heart disease.

1. PROF.DR.P.VIJAYARAGHAVAN’S UNIT
DR.V.MANIKANDAN

2.  A 41 YEAR OLD FEMALE CAME WITH C/O
 BREATHLESSNESS
 PALPITATION FOR A DURATION OF 3 DAYS
PATIENT WAS APPARENTLY NORMAL 3 DAYS BACK,STARTED
DEVELOPING BREATHLESSNESS INITIALLY ON EXERTION NOW AT
REST.H/O OF ORTHOPNEA PRESENT.H/O CHEST PAIN PRESENT.
PAST H/O:H/O OF SURGERY DONE FOR VALVULAR HEART
DISEASE 14 YEARS BACK.
PATIENT HAS NOT BEEN TAKING MEDICATIONS FOR PAST 1
WEEEK.

3.  CONSCIOUS,ORIENTED
 DYSPNEIC,TACHYPNEIC
 PEDAL EDEMA(+)
 NO PALLOR,CYANOSIS,CLUBBING
 VITALS:
 PULSE:140/MT,IRREGULARLY IRREGULAR,VARIABLE VOLUME
 B.P:110/70
 JVP-ELEVATED
 CVS:S1,S2 HEARD,S1 LOUD,MDM(+)
 R.S:NVBS HEARD,B/L BASAL CREPTS PRESENT
 P/A -SOFT

6. REPEAT ECG

7.  A 12 LEAD ECG WITH,
 RATE-160/minute, irregular
 Varying RR interval
 Axis 90 to 120
 Definite discrete p waves not seen.
 RVH with ST-T changes.
 Rpt. ECG shows fibrillatory waves.

8. Possibilities:
 Digitalis effect
 Multifocal Atrial Tachycardia
 Atrial Fibrillation

9. ECHO FINDINGS:
 MODERATE MS,MILD TR
 LA DILATED,NO PHT
 MVA-1.3 SQ.CM

10.  Low amplitude baseline oscillations and an irregularly
irregular ventricular rhythm.
 The f waves have a rate of 300 to 600 beats /min.
 Variable in shape,amplitude and timing.
 Distingushing feature from flutter is absence of
uniform and regular atrial activity in other laeds of
ecg
 chaotic atrial depolarization
 the atria contract irregularly and very rapidly
producing variable R-R intervals
 no regular p waves are identifiable and the baseline
is undulating

11.  RHEUMATIC HEART DISEASE,
 HYPERTENSION,
 ISCHEMIC HEART DISEASE,
 PERICARDITIS,
 THYROTOXICOSIS,
 ALCOHOL INTOXICATION,
 MITRAL VALVE PROLAPSE, AND
 DIGITALIS TOXICITY

12.  Cardiac arrythmia
 Wandering atrial pacemaker
 The electrical impulse is generated at a
different focus within the atria of the heart
each time.

13.  Decompensated chronic lung disease
 Congestive heart failure
 Digitalis toxicity
 Hypokalemia
 Methylxanthine toxicity
MANAGEMENT:
1. TREATMENT OF UNDERLYING CAUSE
2. ANTIARRYTHMICS OFTEN INEFFECTIVE
3. VERAPAMIL OR AMIODARONE HAVE BEEN USEFUL
4. POTTASIUM AND MAGNESIUM REPLACEMNT
EFFECTIVE.
5. ABLATION USEFUL IN SOME CASES.

14. •ECG CHARACTERISTICS:
•DISCRETE P WAVES WITH AT LEAST 3 DIFFERENT
MORPHOLOGIES
• ABSENCE OF ONE DOMINANT ATRIAL PACEMAKER
• ATRIAL RATE BETWEEN 100 AND 130.
• THE PP, PR, AND RR INTERVALS ALL VARY.

15. •LEFT ATRIAL ENLARGEMENT
•RIGHT QRS AXIS DEVIATION
•A WIDE FRONTAL PLANE QRS-T ANGLE
•ATRIAL FIBRILLATION
•A PRECORDIAL MORPHOLOGY WHICH MAY MANIFEST ANY ONE OF
THE FOLLOWING FEATURES
A RELATIVELY NORMAL,NEUTRAL OR UNREMARKABLE
PRESENTATION,
RIGHT VENTRICULAR SYSTOLIC OVERLOAD
RIGHT VENTRICULAR DIASTOLIC OVERLOAD