Cardiac Arrhythmias: The Management of Atrial Fibrillation
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A comprehensive history should be taken, although not all patients with AF will be symptomatic.
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Typical symptoms include; palpitations, tachycardia, tiredness, weakness, dizziness, mild shortness of breath and reduced exercise capacity. Patients may also present with more severe symptoms including; significant shortness of breath, chest pains and fainting. Check when the symptoms started, how often they occur and how long they last. Assess the severity of the symptoms and the presence of any associated features that may suggest an underlying cause such as hyperthyroidism. Ask about any precipitating triggers such as exercise, alcohol or stress.
Examination should include assessment of: pulse rate and rhythm ; blood pressure, jugular venous pressure; heart sounds, e. Approximately one-third of the estimated 35, people in New Zealand with AF will be asymptomatic.
ECG If AF is suspected on the basis of patient history or found incidentally during physical examination, the patient should have an electrocardiogram ECG to confirm the diagnosis. An initial ECG may also show evidence of other abnormalities that could suggest a possible underlying cause of the AF such as an old myocardial infarction MI or left ventricular hypertrophy. Other conduction abnormalities may be present such as pre-excitation short PR interval or bundle branch block. Assessment of the QT interval may be required prior to initiation of some anti-arrhythmic medicines such as amiodarone, sotalol and disopyramide.
Blood tests Blood tests are indicated to rule out any underlying condition that may have triggered AF. Echocardiography All patients with newly diagnosed AF should ideally be referred for transthoracic echocardiography. This provides information that is helpful in assessing thromboembolic risk, particularly in relation to left ventricular function. Other investigations Depending on the clinical situation, patients with AF may require referral for other investigations including:. The majority of people presenting with symptoms consistent with new onset AF will not be haemodynamically compromised, however, urgent referral to secondary care for possible cardioversion is required if the patient has: 6.
In most acutely symptomatic patients, AF will be of new onset, however, in some patients it may be difficult to determine whether the AF is actually of new onset or rather is newly identified. An underlying condition can also trigger AF and reversion to sinus rhythm may result from appropriate treatment of the underlying condition. AF is generally classified into three types, although this may require further investigations and cardiologist input to determine. Knowing the type helps to guide treatment decisions regarding rate or rhythm control. Rate or rhythm control? The choice between rate or rhythm control is guided by the type of AF and other factors such as age, the presence of co-morbidities, the presence or absence of symptoms and patient preference.
Clinical trials have not shown any significant differences between rate or rhythm control with respect to rates of stroke and mortality. Improvements in quality of life are seen with both treatment approaches. Rate control is recommended for the majority of patients. Any concerns about a strategy of rate control for a particular patient can be discussed with a cardiologist. Rhythm control, which aims to restore and maintain sinus rhythm, should be considered for patients with: 4,7. All patients for whom a rhythm control strategy is contemplated should be referred to a cardiologist. Rate control medicines The ventricular rate may be controlled using beta blockers, rate limiting calcium channel blockers verapamil or diltiazem or digoxin.
The choice of a medicine for rate control in patients in primary care should be guided by the presence of co-morbidities and also by the level of activity of the patient. Table 1 lists first to fourth-line options for rate control.
Medicines may be used singularly or in combination. A patient who is active is unlikely to achieve rate control with digoxin alone. Patients who achieve poor rate control on maximally tolerated first, second or third-line medicines used in combination, particularly with ongoing symptoms, should be referred to a cardiologist for consideration of additional treatment options. This may include amiodarone, AF ablation or AV node ablation with pacemaker implantation. Consultation with a cardiologist is also recommended if there is any uncertainty over which combinations of medicines to use.
Rhythm Control All patients, for whom rhythm control is considered to be the most appropriate treatment option, should be referred to a cardiologist. Sinus rhythm can be restored using electrical or pharmacological cardioversion, e. AF may recur after electrical or pharmacological cardioversion therefore ongoing rhythm control with antiarrhythmic medicines will usually be required. A brief overview of some of the available options follows — for more detailed information refer to the European Society of Cardiology Guideline.
Medicines that are commonly used to achieve or maintain rhythm control after restoration of sinus rhythm include:. Radiofrequency ablation of AF is a new treatment option and may be considered in patients with significant limiting symptoms despite medical treatment or patients who wish to consider this treatment for lifestyle reasons. AF is associated with a pro-thrombotic state and an approximately five-fold increase in stroke risk. The risk of stroke is the same regardless of whether the patient has paroxysmal or sustained permanent or persistent AF.
Bleeding risk should be estimated to help assess the risk-benefit ratio prior to choosing appropriate antithrombotic treatment. Aspirin may be considered for patients with AF who are unsuitable for anticoagulation. Also consider co-morbidities, monitoring requirements and patient preference when determining whether anticoagulation is suitable.
Once the decision to anticoagulate has been made, the next decision is whether to use warfarin or dabigatran. All patients with haemodynamically significant valvular disease or a prosthetic valve should be anticoagulated with warfarin. There are a number of guidelines available for the management of AF. Follow us on facebook. Forgot your login? Login to my bpac. Remember me. Cardiovascular system Haematology.
Penn Cardiac Arrhythmia Program – Penn Medicine
Management of atrial fibrillation in general practice Atrial fibrillation AF is often an incidental finding during a routine medical assessment. In this article What is atrial fibrillation?
Collection 01 May Atrial fibrillation AF is the most prevalent sustained cardiac arrhythmia, and is associated with a substantial economic burden. Atrial fibrillation occurs when cardiac electrical impulses become disordered, leading to a rapid and irregular heartbeat.
Lip and colleagues discuss the mechanisms that underlie this common arrhythmia and outline current strategies and potential future developments for its diagnosis and management. Differences between women and men with atrial fibrillation have received far less attention in recent years than sex-specific differences in coronary heart disease and stroke. In this Review, Ko et al. To bridge the current gap between the known mechanisms of atrial fibrillation AF and the clinical management of patients with this arrhythmia, Fabritz and colleagues propose a roadmap to develop a set of clinical markers that reflect the major causes of AF in patients.
A new, mechanism-based classification of AF can provide the basis for personalized prevention and management.
Atrial fibrillation AF and heart failure HF are evolving epidemics with increasing global prevalence. In this Review, Ling and colleagues present the current understanding of the epidemiology and pathophysiology of AF—HF, and the roles of pharmacological and interventional therapies in the management of patients with this comorbidity. Patients with sinus node disease SND and an implanted cardiac pacemaker have high prevalence of atrial tachyarrhythmias and atrial fibrillation AF.
In this Review, Boriani and Padeletti describe new developments in pacemaker technology that enable continuous monitoring of the atrial rhythm and allow detection of the burden of AF. These clinical advances could improve guidelines and management of AF and atrial tachyarrhythmias. An increasing body of evidence suggests that proteins involved in the inflammatory response are also involved in the pathophysiology of atrial fibrillation AF.
Moreover, AF itself can induce inflammation. In this Review, Hu and colleagues discuss the interplay between inflammation and AF. The authors also highlight potential therapies that might be used to treat inflammation-induced AF.