Atrial Fibrillation (A Fib)


Article Author:
Zeid Nesheiwat


Article Editor:
Mandar Jagtap


Editors In Chief:
Michael Labanowski


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
3/9/2019 10:08:43 PM

Introduction

Atrial fibrillation is the most common type of heart arrhythmia. It is due to abnormal electrical activity within the atria of the heart causing them to fibrillate. Is characterized as a tachyarrhythmia, which means that the heart rate is often fast. This arrhythmia may be paroxysmal (less than 7 days) or persistent (more than 7 days). Due to its rhythm irregularity, blood flow through the heart becomes turbulent and has a high chance of forming a thrombus (blood clot) which can ultimately dislodge and cause a stroke. Atrial fibrillation is the leading cardiac cause of stroke. Risk factors for atrial fibrillation include advanced age, high blood pressure, underlying heart and lung disease, congenital heart disease, and increased alcohol consumption. Symptoms vary from asymptomatic to symptoms such as chest pain, palpitations, fast heart rate, shortness of breath, nausea, dizziness, diaphoresis (severe sweating), and generalized fatigue. Although atrial fibrillation may be a permanent disease, various treatments have been developed, and risk modifying strategies to help reduce the risk of stroke in patients that remain in atrial fibrillation exist. Treatments include anticoagulation, rate control medication, rhythm control medication, cardioversion, ablation, and other interventional cardiac procedures. [1][2][3]

Etiology

There are many causes of atrial fibrillation. Advanced age, congenital heart disease, underlying heart disease (valvular disease, coronary artery disease, structural heart disease), increased alcohol consumption, hypertension, and obstructive sleep apnea are all common causes of atrial fibrillation. Any process that causes inflammation, stress, damage, and ischemia to the structure and electrical system of the heart can lead to the development of atrial fibrillation. In some cases, the cause is iatrogenic.[4]

Epidemiology

The prevalence of atrial fibrillation has been increasing worldwide. It is known that the prevalence of atrial fibrillation generally increases with age. It has been estimated that the number of individuals with atrial fibrillation will double or triple by the year 2050. Although the world white prevalence of atrial fibrillation is approximately 1%, it is found in approximately 9% in individuals over the age of 75. At the age of 80, the lifetime risk of developing atrial fibrillation jumps to 22%. In addition, atrial fibrillation has more commonly been associated with males and seen more often in whites as compared to black.[5][6]

Pathophysiology

There are a wide variety of pathophysiology mechanisms that play a role in the development of atrial fibrillation. Most commonly, hypertension, structural, valvular, and ischemic heart disease illicit the paroxysmal and persistent forms of atrial fibrillation but the underlying pathophysiology is not well understood. Some research has shown evidence of genetic causes of atrial fibrillation involving chromosome 10 (10q22-q24) that involves a mutation in the gene, alpha-subunit of the cardiac Ik5, which encodes pore formation protein. This mutation increases the function of this protein allowing for more pores, and thus, activity within the ion channels of the heart, therefore affecting the stability of the membranes and reducing its refractory time. [1] 

Most cases of atrial fibrillation are non-genetic and relate to underlying cardiovascular disease. Typically, an initiating trigger excites an ectopic focus in the atria, most commonly around the area of the pulmonary veins, and allows for an unsynchronized firing of impulses and electricity leading to fibrillation of the atria. These impulses are irregular, and pulse rates can vary tremendously. Overall, atrial fibrillation leads to a turbulent and abnormal flow of blood through the heart chamber decreasing the heart effectiveness to pump blood while increasing the likelihood of thrombus formation within the atria, most commonly the left atrial appendage.

History and Physical

History and physical exam are crucial for diagnosing and risk stratifying patients with atrial fibrillation. A complete history should focus on symptoms such as palpitations, chest pain, shortness of breath, increased lower extremity swelling, dyspnea with exertion, dizziness, among others. In addition, history is imperative in identifying risk factors such as hypertension, history of valvular, structure, or ischemic heart disease, obstructive sleep apnea, obesity hypoventilation syndrome, smoking, alcohol intake, illicit drug use, history of rheumatic fever/heart disease, history of pericarditis, hyperlipidemia, among others. A physical exam should include the patient's overall appearance (obese), examine the patient neck for signs of JVD, carotid bruits, circumference. A cardiovascular exam should consist of carefully auscultating all 4 cardiac posts and palpating for apical impulse. A pulmonary exam should consist of auscultation, percussion, and specialized tests, if needed, to assess pulmonary status. Extremities should be evaluated for edema, peripheral pulses in both upper and lower extremities, and integumentary signs of PVD such as hair loss and skin breakdown. An abdominal exam should consist of palpating the aorta and listening for abdominal bruits. Depending on the severity of the atrial fibrillation, signs, and symptoms can range from none to evidence of acute heart failure.

Evaluation

Aside from a detailed history and examine, the ECG is critical in making the diagnosis of atrial fibrillation. On ECG, atrial fibrillation presents with the typical narrow complex "irregularly irregular" pattern with no distinguishable p-waves. Laboratory work is required to evaluate for the causes of atrial fibrillation, for example, a complete blood count (CBC) for infection, basic metabolic panel (BMP) for electrolyte abnormalities, thyroid function tests to evaluate for hyperthyroidism, and a chest x-ray to evaluate the thorax for any abnormality. It is imperative to evaluate the patient for pulmonary embolism (for example with d-dimer, CT scan) because right heart strain can lead to atrial malfunctioning and result in atrial fibrillation. The patient should be risk stratified for pulmonary embolism using the PERC and/or Wells criteria. In addition, a transesophageal echocardiogram should be done for these patients to evaluate for atrial thrombus secondary to atrial fibrillation and heart structure. It is important to note that Transesophageal echocardiogram (TEE) should always be done prior to cardioversion for these patients to minimize the risk of stroke.[7][8]

Treatment / Management

The management of atrial fibrillation in the acute setting relies on patient hemodynamic stability and risk stratification. If the patient is hemodynamically unstable, immediate cardioversion with anticoagulant therapy is indicated. TEE is recommended prior to any cardioversion; however, if the patient is in hemodynamic stability due to atrial fibrillation with a rapid ventricular response, cardioversion may be performed without prior TEE. If the patient has evidence of rapid ventricular response, rate control should be initiated using a beta-blocker or calcium-channel blocker. These medications can be used as intravenous (IV) pushes or drips. Typically, the patient is given a bolus then started on a drip if symptoms do not resolve. Digoxin can be considered as a rate control agent but is not recommended as a first-line agent due to its side-effects and tolerance. Amiodarone can also be considered for a rhythm controlling agent but is also not first-line therapy in the acute setting. Amiodarone is also considered as a rhythm control, but cardiology should be consulted prior to use.

In the chronic setting of atrial fibrillation, the patient should be risk stratified using the CHADs-2-Vasc score which is helpful in estimate risk of CVA per year. If the patient receives a 0 score, they will be considered "low-risk" and anticoagulation is not recommended. If the patient receives a score of 1, they are "low-moderate" risk; the physician should consider anticoagulant or antiplatelet therapy. If the patient receives a score of greater than 2, they are in the "moderate-high" risk, and anticoagulation therapy is indicated.[2] Rate or rhythm control should also be given to the patient, medications such as beta-blockers, calcium channel blockers, amiodarone, dronedarone, and digoxin. HAS-BLED is also a scoring system that can be used to asses the risk of bleeding for the patient. This is a good indicator of bleeding risk for a patient that is considering starting anticoagulation.

Non-pharmacological therapy includes ablation therapy. Pacemaker placement is considered in severe causes resulting in heart failure in atrial fibrillation.[9][10][11]

Differential Diagnosis

Differential diagnosis includes atrial flutter; however atrial fibrillation has the distinctive irregularly irregular rhythm with absent P-waves whereas atrial flutter has a regularly irregular rhythm with absent P-waves.

Staging

Classification of atrial fibrillation

  1. Paroxysmal AF is when the episodes terminate spontaneously or with treatment within 7 days. But they may recur with an unpredictable frequency
  2. Persistent AF is when the AF is continuous and lasts for more than 7 days, and fails to terminate spontaneously.
  3. Long-standing AF is when the continuous AF lasts more than 12 months
  4. Permanent is when AF is accepted and no further treatments are attempted to restore or maintain normal sinus rhythm
  5. Non-valvular AF occurs in the absence of rheumatic mitral valve disease, mitral valve repair or a prosthetic heart valve.

Complications

The major side effect of atrial fibrillation is a stroke. Cerebral vascular accident (CVA) can lead to severe morbidity and mortality. CVA risk can be reduced significantly by anticoagulation with adjunct rate/rhythm therapy. Other complications include heart disease and heart failure secondary.

Consultations

Cardiology consultation is recommended for a patient with atrial fibrillation.

Pearls and Other Issues

Atrial fibrillation is a common disease that affects many individuals. The prevalence of this disease increases with age with the most severe complication being acute CVA. Due to the irregularly of the atria, blood blow through this chamber becomes turbulent leading to a blood clot (thrombus). This thrombus is commonly found in the atrial appendage. The thrombus can dislodge and embolize to the brain and other parts of the body. It is important for the patient to seek medical care immediately if they are experiencing chest pain, palpitations, shortness of breath, severe sweating, or extreme dizziness.

Enhancing Healthcare Team Outcomes

Atrial fibrillation is a chronic disorder that can seriously affect the quality of life and costs the healthcare billions of dollars each year. While cardiologists treat the disorder, the role of the pharmacist is critical. Many of these patients are on multiple medications including antiarrhythmic agents and anticoagulants. In addition, there is some evidence indicating that use of Angiotensin receptor blockers and statins may lower the frequency of atrial fibrillation and increase the probability of successful cardioversion. Thus, the pharmacist has to make sure that the patient' medication doses are therapeutic, there are no drug interactions and that the patient has therapeutic anticoagulation to prevent a stroke. The nurse has to educate the patient on medication compliance for hypertension, coronary disease and ensure follow-up at regular intervals. Finally, the patient should be educated about the symptoms of a stroke and when to return to the emergency department.[12][13][14] (Level V)

Outcomes

Atrial fibrillation prevalence has been on the rise. The risk of stroke is 5-times higher in a patient with known atrial fibrillation compared to the general public. It is estimated that 19.6% of patients over the age of 65, will have apparent atrial fibrillation by 2030. The most feared side effect of atrial fibrillation is acute stroke which can lead to severe morbidity and mortality. It has been shown though that 60% of strokes secondary to atrial fibrillation can be avoided with the use of anticoagulants. Using the CHADs-2-VASc score to evaluate patients with atrial fibrillation is a helpful guide for management of these patients with the ultimate goal of preventing stroke. Proper risk factor stratification and medical/surgical therapy can decrease the risk of stroke and heart failure significantly.[3]


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Atrial Fibrillation (A Fib) - Questions

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In a 44-year-old, what is the biggest risk factor for atrial fibrillation?



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What is not a feature on ECG in a patient with atrial fibrillation or flutter?



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A 65-year-old with atrial fibrillation is at highest risk for what complication?



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What is the best treatment for a 46-year-old who has atrial fibrillation that started 24 hours ago?



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In a patient with atrial fibrillation and a high ventricular rate, what drug is recommended before cardioversion?



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Which of the following medical disorders can increase the risk of developing atrial fibrillation?



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Which of the following interventions should be avoided in a patient with Wolff-Parkinson-White syndrome who is experiencing atrial fibrillation?



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A 55-year-old previously healthy male has been complaining of heart palpitations for the past 3 months. After a quick physical exam, the ECG reveals that he has atrial fibrillation. Five minutes later, the patient is unresponsive and has a blood pressure of 60/20 mmHg and a heart rate of 157 beats/min. What is next best step in management?



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A 70-year-old male with congestive heart failure develops symptomatic atrial fibrillation 2 days post surgery. His blood pressure is 97/60 mmHg and his pulse is greater than 135 bpm. His respirations are 22 times a minute. What is the best treatment for this patient?



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A 67-year-old male with a history of hypertension is diagnosed with atrial fibrillation following a transient ischemic attack. He is currently on antihypertensive and antiarrhythmic therapy. On discharge, which of the following should be added to the treatment plan?



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A 65-year-old female is diagnosed with atrial fibrillation. She is asymptomatic after successful rate control with a beta-blocker and is found to have left atrial enlargement and an ejection fraction of 45% on echocardiogram. What is the most appropriate management?



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When is cardioversion for atrial fibrillation most successful?



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Which of the following is least effective for preventing atrial fibrillation after cardiac surgery?



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The maze procedure is used to reduce atrial fibrillation by cutting which of the following?



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Which medication is often used to prevent stroke in patients with chronic atrial fibrillation?



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An elderly patient was cardioverted from unstable atrial fibrillation to normal sinus rhythm. His blood pressure is 120/70 mmHg. What is the next step in the management of this patient?



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A 66-year-old male is being worked up for recurrent syncopal episodes present for the past five months. Cardiac workup is unrevealing until he becomes symptomatic in the middle of the night. EKG reveals atrial fibrillation with a heart rate of 144 beats minute. What is the appropriate next step?



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A 66-year-old male presents with a fainting episode. His blood pressure is 63/45 mmHg. He is diaphoretic and confused. ECG reveals tachycardia with absent P waves. What is the most appropriate next step in the management of this patient?



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Which statement about oral anticoagulation in atrial fibrillation is true?



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An elderly patient presents with new onset atrial fibrillation. Echocardiogram reveals a left atrial thrombus but no other pathology. The patient is rate controlled first with intravenous, and then with oral diltiazem, but still experiences intermittent palpitations. Prior to cardioversion, which of the following is the best course of action?



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An elderly female has atrial fibrillation with a rapid ventricular response of 185 bpm. Respiratory rate is 28 bpm, BP is 86/66 and chest x-ray reveals cardiomegaly and pulmonary edema. Patient appears short of breath. What is the next step in her treatment?



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Why is a 67-year-old with atrial fibrillation prescribed warfarin?



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A 63 year old female with a history of paroxysmal atrial fibrillation and hypertension presents with an episode of 6 hours duration. The patient denies chest pain or shortness of breath. Medications include lisinopril and aspirin. Blood pressure is 105/75 mmHg. ECG shows atrial fibrillation with a ventricular response rate of 150 without acute changes. Select appropriate management.



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Which of the following statements about anticoagulation in atrial fibrillation is true?



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How long is anticoagulation continued after cardioversion for atrial fibrillation?



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A 73 year old female has diabetes and chronic non-valvular atrial fibrillation. She is on metoprolol for rate control. She has not had a CVA or TIA. Which of the following should be started for prevention of strokes?



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A patient taking metoprolol for atrial fibrillation experiences symptomatic bradycardia. Which of the following medications is likely a synergistic culprit?



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Permanent atrial fibrillation (AF) is defined as lasting:



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Persistent atrial fibrillation (AF) is defined as lasting:



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Which of the following is a cornerstone of treatment for atrial fibrillation?



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Which of the following is a first-line agent for rate control in the management of atrial fibrillation (AF)?



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The INR goal for anticoagulation in a patient with atrial fibrillation (AF) is:



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At what interval is cardioversion most effective in patients with atrial fibrillation (AF)?



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Which of the following antiarrhythmic medications is not used to treat atrial fibrillation?



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Which of the following medications only controls rate in atrial fibrillation (AF)?



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Which of the following can be used to maintain sinus rhythm after direct current cardioversion for atrial fibrillation?



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A 47-year-old male has been in atrial fibrillation for 3 weeks. He has no history of stroke, hypertension, diabetes mellitus, or tobacco use. A cardiovascular exam shows that S1 and S2 are irregularly irregular without an extra heart sound. Lungs are clear to auscultation and percussion. There is no jugular venous distension or pedal edema. An echocardiogram shows the left atrial size to be 3.6 centimeters and the ejection fraction is 60%. There are no valvular abnormalities or hypertrophy. Which of the following is true?



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Which is a first-line drug for rate control in the long-term management of atrial fibrillation that is stable but symptomatic?



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Which is true of the arterial pulse in patients with atrial fibrillation?



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What is the main etiology of a potential complication of atrial fibrillation?



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A 60-year-old male with atrial fibrillation is involved in a motor vehicle accident and sustains a compound fracture of the right femur. Ten days later, the patient presents with right-sided paralysis, left flank pain, and hematuria. What is the most likely cause of the new findings?



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A patient is instructed about the digoxin he is prescribed for atrial fibrillation. Which teaching point is least crucial that he understands which of the following?



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A 56 year old male undergoes a mechanical aortic valve replacement. Post operatively he has developed atrial fibrillation. What is his target INR?



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A 65-year-old female presents to the emergency department with vague symptoms of fatigue that is worse with exertion. She is found to be in atrial fibrillation with rapid ventricular response on ECG. Her workup for infection or other cause is negative. Sitting in the emergency department, she is asymptomatic. What is the appropriate next step?



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A 64 year old female with baseline NYHA class 3 systolic heart failure develops atrial fibrillation during a hospitalization for acute decompensated heart failure. Her heart failure is deemed secondary to dilated cardiomyopathy. A cardiac catheterization has revealed normal coronary arteries without significant stenosis. You decide to pursue a rhythm control strategy. Her estimated creatinine clearance is 70 ml/min. Which of the following regimens would be most appropriate for rhythm control?



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Which is true of atrial fibrillation?



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Which of the following does not support the diagnosis of atrial fibrillation?



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A 68-year-old female with atrial fibrillation becomes hypotensive while in the hospital. Her heart rate is too fast to assess a pulse. What is the best treatment?



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A male patient is at high risk for atrial fibrillation with normal valves. It is decided to treat him with an oral anticoagulant agent. Which of these anticoagulants should be used?



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A female patient with atrial fibrillation is going to be cardioverted and started on oral anticoagulant therapy. What is the minimum time she must have had atrial fibrillation to be eligible for the anticoagulant therapy?



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A male patient with nonvalvular atrial fibrillation is started on warfarin. He would like to know how much his stroke risk will be reduced each year with this medication. How much is the reduction?



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A middle-aged patient presents with chest discomfort and sensations of a rapid heartbeat on a regular basis. The patient had coronary artery bypass a few months ago and soon developed the palpitations. He denies any dizziness, syncopal episodes or dyspnea. He did have an echocardiogram after surgery which revealed that the ejection fraction was 45% and there was no evidence of valvular dysfunction. However, soon after the bypass, he did have a mild intracranial bleed which did not cause any neurological deficits. His rhythm strip is shown below. It is now deemed that he may be at moderate risk for intracranial hemorrhage. According to current guidelines by the American Association of Neurology, which medication should be avoided in this patient?

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  • Image 5992 Not availableImage 5992 Not available
    Contributed by S Bhimji MD
Attributed To: Contributed by S Bhimji MD



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A 68-year- old female with no prior cardiac history presents to the emergency department with a productive cough, fever, and shortness of breath. Initial vitals are heart rate 130 bpm, respiratory rate 30/min, blood pressure 110/60 mmHg, temperature 39.0 C. Initial laboratory analysis is significant for a white blood cell count of 30,000 cells/microL. A chest x-ray shows pneumonia. Her EKG shows atrial fibrillation. What is the most appropriate treatment for her arrhythmia?



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A 58-year-old male with past medical history of diabetes mellitus, hypertension, and hyperlipidemia presents to the emergency department with the complaint of sudden onset chest pain. On physical exam, he is cool to the touch, pale, and diaphoretic. He has crackles bilaterally on lung auscultation. Initial vitals are heart rate 160 bpm, blood pressure 70/50 mmHg, and temperature 37.0 C. His EKG shows atrial fibrillation with ST elevation in leads I, aVL, V5, and V6. What is the most appropriate treatment for this patients heart rate?



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A 35-year-old male with recently diagnosed atrial fibrillation presents to the hospital with a syncopal episode. He is found to have atrial fibrillation with a ventricular rate of 86 on EKG. The patient had a recent echocardiogram showing no valvular heart disease or other structural heart changes. He is on metoprolol for rate control. He also reports that he is having limitation of his physical activity for the past 2 months and has recently noticed frequent palpitation even at rest. What therapeutic intervention is most likely to improve his symptoms and quality of life.



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A 35-year-old African American female with past medical history of type 2 diabetes mellitus and hyperlipidemia presents to her primary care physician’s clinic with symptoms of dizziness and palpitations. On physical examination, she has a heart rate of 110 bpm; blood pressure is 120/76 mmHg, respiratory rate of 18/minute, and temperature of 97.8 F. An electrocardiogram shows a narrow QRS complex tachycardia with an irregular rhythm. What is the most likely diagnosis?



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A 65-year-old female is admitted to the hospital with palpitations and shortness of breath. Her past medical history includes congestive heart failure with an ejection fraction of 28%, hypertension, and asthma. She reports smoking 4 to 5 cigarettes a day but no illicit drug use. She takes amlodipine 10 mg once a day, lisinopril 10 mg a day and uses an albuterol inhaler about once a month in the spring and fall). Physical exam reveals blood pressure 140/80 mmHg, heart rate 164 bpm, irregular, respiratory rate 20. EKG results show atrial fibrillation. What is an appropriate rate control medication for her that would also be useful for her congestive heart failure?



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After open heart surgery, a patient on postoperative day 3 developed the rhythm shown in the image below. What is true about this rhythm? Select all that apply.

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  • Image 6478 Not availableImage 6478 Not available
    Contributed by Steve Bhmji, MS, MD, PhD
Attributed To: Contributed by Steve Bhmji, MS, MD, PhD



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While in the intensive care unit for chest pain, a client suddenly develops the abnormal heart rhythm shown in the image below. The client had been in normal sinus rhythm previously with no history of an irregular heartbeat. The client's blood pressure is 110/80 mmHg, pulse varies from 108 to 134 beats/min, and the respiratory rate is 18. The client is anxious and feels a funny sensation in their throat. The client has pink, warm, dry skin and is alert and oriented. What is the next step in the nursing management of this client's care? Select all that apply.

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  • Image 6140 Not availableImage 6140 Not available
    Image courtesy s.bhimji MD
Attributed To: Image courtesy s.bhimji MD



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A patient has been having palpitations for the past several months. He denies the use of any drugs or any past problems with his health. A 12-lead ECG reveals that the patient has the rhythm shown below. Which of the following is true about this rhythm? Select all that apply.

(Move Mouse on Image to Enlarge)
  • Image 6479 Not availableImage 6479 Not available
    Contributed by Steve Bhmji, MS, MD, PhD
Attributed To: Contributed by Steve Bhmji, MS, MD, PhD



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A 76-year-old male comes into the emergency department with a complaint of chest pain. The patient was placed on telemetry monitoring that showed an abnormal rhythm at a rate of 160 beats per minute. A 12 lead EKG was performed showing an irregularly irregular rhythm. He has a history of atrial fibrillation and has been taking rivaroxaban for the past four months. The patient soon becomes diaphoretic, unresponsive, and hypotensive. What is the next best step?



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A 56-year-old male was admitted to the hospital for new-onset atrial fibrillation. After a failed attempts of pharmacologic therapy to return the patient to normal sinus rhythm, the decision was to perform a transesophageal echocardiogram (TEE)/cardioversion. When performing the TEE, the patient was found to have a left atrial appendage thrombus, and therefore cardioversion was aborted. The patient was then started on rivaroxaban. When should cardioversion be considered again for this patient?



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A 59-year-old female with a past medical history of coronary artery disease, hypertension, hyperlipidemia, obesity, gastroesophageal reflux disease, and alcohol dependence presents to the emergency department with acute onset shortness of breath for one day. She has dry cough and nausea. Vitals shows heart rate of 138/min, respiratory rate 32/min, temperature 99 F, and blood pressure is 142/92 mmHg. Oral mucosa is dry, and her breath smells of alcohol. Lungs exam reveals fine bibasilar crackles and the neck exam is unremarkable. Also, the EKG shows an irregularly irregular rhythm. Labs indicate a raised blood alcohol level and TSH is 0.36 mU/L. Diltiazem infusion is initiated along with fluids. Which of the following is the best management plan for this patient?



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Atrial Fibrillation (A Fib) - References

References

Markides V,Schilling RJ, Atrial fibrillation: classification, pathophysiology, mechanisms and drug treatment. Heart (British Cardiac Society). 2003 Aug     [PubMed]
Amin A,Houmsse A,Ishola A,Tyler J,Houmsse M, The current approach of atrial fibrillation management. Avicenna journal of medicine. 2016 Jan-Mar     [PubMed]
McManus DD,Rienstra M,Benjamin EJ, An update on the prognosis of patients with atrial fibrillation. Circulation. 2012 Sep 4     [PubMed]
Mohanty S,Trivedi C,Gianni C,Natale A, Gender specific considerations in atrial fibrillation treatment: a review. Expert opinion on pharmacotherapy. 2018 Mar     [PubMed]
Peters SAE,Woodward M, Established and novel risk factors for atrial fibrillation in women compared with men. Heart (British Cardiac Society). 2018 Aug 29     [PubMed]
Choi YJ,Choi EK,Han KD,Jung JH,Park J,Lee E,Choe W,Lee SR,Cha MJ,Lim WH,Oh S, Temporal trends of the prevalence and incidence of atrial fibrillation and stroke among Asian patients with hypertrophic cardiomyopathy: A nationwide population-based study. International journal of cardiology. 2018 Aug 11     [PubMed]
Robert R,Porot G,Vernay C,Buffet P,Fichot M,Guenancia C,Pommier T,Mouhat B,Cottin Y,Lorgis L, Incidence, Predictive Factors, and Prognostic Impact of Silent Atrial Fibrillation After Transcatheter Aortic Valve Implantation. The American journal of cardiology. 2018 Aug 1     [PubMed]
Tarride JE,Quinn FR,Blackhouse G,Sandhu RK,Burke N,Gladstone DJ,Ivers NM,Dolovich L,Thornton A,Nakamya J,Ramasundarahettige C,Frydrych PA,Henein S,Ng K,Congdon V,Birtwhistle RV,Ward R,Healey JS, Is Screening for Atrial Fibrillation in Canadian Family Practices Cost-Effective in Patients 65 Years and Older? The Canadian journal of cardiology. 2018 Jun 21     [PubMed]
Karnad A,Pannelay A,Boshnakova A,Lovell AD,Cook RG, Stroke prevention in Europe: how are 11 European countries progressing toward the European Society of Cardiology (ESC) recommendations? Risk management and healthcare policy. 2018     [PubMed]
Laäs DJ,Naidoo M, Oral anticoagulants and atrial fibrillation: A South African perspective. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde. 2018 Jul 25     [PubMed]
Bai CJ,Madan N,Alshahrani S,Aggarwal NT,Volgman AS, Sex Differences in Atrial Fibrillation-Update on Risk Assessment, Treatment, and Long-Term Risk. Current treatment options in cardiovascular medicine. 2018 Aug 27     [PubMed]
Brieger D,Amerena J,Attia JR,Bajorek B,Chan KH,Connell C,Freedman B,Ferguson C,Hall T,Haqqani HM,Hendriks J,Hespe CM,Hung J,Kalman JM,Sanders P,Worthington J,Yan T,Zwar NA, National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the diagnosis and management of atrial fibrillation 2018. The Medical journal of Australia. 2018 Aug 2     [PubMed]
Pharithi RB,Ranganathan D,O'Brien J,Egom EE,Burke C,Ryan D,McAuliffe C,Vaughan M,Coughlan T,Morrissey E,McHugh J,Moore D,Collins R, Is the prescription right? A review of non-vitamin K antagonist anticoagulant (NOAC) prescriptions in patients with non-valvular atrial fibrillation. Safe prescribing in atrial fibrillation and evaluation of non-vitamin K oral anticoagulants in stroke prevention (SAFE-NOACS) group. Irish journal of medical science. 2018 Jun 2     [PubMed]
Dan GA,Iliodromitis K,Scherr D,Marín F,Lenarczyk R,Estner HL,Kostkiewicz M,Dagres N,Lip GYH, Translating guidelines into practice for the management of atrial fibrillation: results of an European Heart Rhythm Association Survey. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2018 Jun 8     [PubMed]

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