ECG: New onset AF with slow ventricular response


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ECG: New onset AF with slow ventricular response

  1. 1. ECG OF THE WEEK Prof.Dr.P.Vijayaraghavan’s unit Dr.C.R.Rajkumar M6 unit
  2. 2. <ul><li>65 year old lady presented with breathlessness to the OPD. </li></ul><ul><li>No significant past history. </li></ul><ul><li>On Examination: </li></ul><ul><ul><li>Pulse was irregularly irregular, varying in volume. </li></ul></ul><ul><ul><li>Rate – 50/min, Pulse deficit 11/min. BP – 110/70 </li></ul></ul><ul><ul><li>CVS – S1 varying in intensity. No murmurs. </li></ul></ul><ul><li>ECG was taken. </li></ul>
  3. 4. ECG SHOWS <ul><li>Ventricular Rate of 60/min </li></ul><ul><li>Varying RR interval </li></ul><ul><li>QRS Axis 35 </li></ul><ul><li>QRS Duration 100ms </li></ul><ul><li>QRS morphology normal, occasional artifacts </li></ul><ul><li>No ST segment T wave changes </li></ul><ul><li>Absent P waves </li></ul><ul><li>Undulating baseline </li></ul><ul><li>. </li></ul>
  4. 5. DIAGNOSIS <ul><li>New onset Atrial Fibrillation with slow ventricular response </li></ul>
  5. 6. DD FOR AF WITH SLOW VENTRICULAR RESPONSE: <ul><li>High vagal tone </li></ul><ul><li>AF with associated AV heart block </li></ul><ul><li>Digoxin effect </li></ul><ul><li>Beta blocker and other drugs </li></ul>
  6. 7. ATRIAL FIBRILLATION <ul><li>The most common sustained cardiac rhythm disturbance </li></ul><ul><li>Def: Supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of atrial mechanical function. </li></ul>
  7. 8. MECHANISM <ul><li>Atrial factors: </li></ul><ul><li>Enhanced automaticity in 1 or several rapidly depolarizing foci and reentry involving 1 or more circuits. </li></ul><ul><li>The multiple-wavelet hypothesis: that fractionation of the wave fronts as they propagate through the atria results in self-perpetuating “daughter wavelets </li></ul>
  8. 9. CLASSIFICATION: <ul><li>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 </li></ul><ul><li>Recurrent AF : </li></ul><ul><ul><li>(1) Paroxysmal AF (self terminating, episodes <7 days) </li></ul></ul><ul><ul><li>(2) Persistent AF (not self terminating usually greater than 7 days) </li></ul></ul><ul><ul><li>(3) Permanent AF (cardio version failed or not attempted) </li></ul></ul>
  9. 10. MYOCARDIAL AND HEMODYNAMIC CONSEQUENCES <ul><li>3 factors affect hemodynamic function: </li></ul><ul><li>loss of synchronous atrial mechanical activity. </li></ul><ul><li>Irregularity of ventricular response. </li></ul><ul><li>Inappropriately rapid heart rate </li></ul>
  10. 11. MYOCARDIAL AND HEMODYNAMIC CONSEQUENCES <ul><li>A persistently rapid atrial rate can adversely affect atrial mechanical function (tachycardia-induced atrial cardiomyopathy) </li></ul><ul><li>A persistently elevated ventricular rate during AF can produce dilated ventricular cardiomyopathy. </li></ul><ul><li>HF can be the initial manifestation of AF </li></ul>
  11. 12. COMMON CAUSES <ul><li>10% elderly, more than 75 yrs </li></ul><ul><li>Lone AF less than 65 yrs </li></ul><ul><li>Valvular heart disease </li></ul><ul><li>Hypertension </li></ul><ul><li>Myocarditis and cardiomyopathy </li></ul><ul><li>Cardiac surgery </li></ul><ul><li>Hyperthyroidism </li></ul><ul><li>Alcohol poisoning </li></ul><ul><li>Autonomic dysfunction </li></ul><ul><li>SVT </li></ul><ul><li>Sick sinus syndrome </li></ul>
  12. 13. CLINICAL MANIFESTATIONS <ul><li>Symptoms vary with the ventricular rate, underlying functional status, duration of AF and individual patient perceptions. </li></ul><ul><li>Most patients with AF complain of palpitations, chest pain, dyspnea, fatigue, or light headedness, polyuria, syncope. </li></ul>
  13. 14. IF UNSTABLE <ul><ul><li>Cardioversion </li></ul></ul>
  14. 15. IF STABLE <ul><li>Rate control </li></ul><ul><li>Minimize thrombo-embolic risk . </li></ul><ul><li>Establish etiology </li></ul><ul><li>Restore sinus rhythm </li></ul><ul><li>Maintain sinus rhythm </li></ul>
  15. 16. PLAN FOR THIS PATIENT: <ul><li>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. </li></ul><ul><li>Echo to rule out structural heart disease. </li></ul><ul><li>TEE (Trans-Esophageal Echo) for LA clot. </li></ul>