CHART 387

Dysrhythmia Premature atrial contraction

Atrial Dysrhythmias: Etiology, Physical Assessment, and Treatment

Etiology Mitral stenosis Mitral valve prolapse Cor pulmonale Underlying cardiovascular disease including ischemia and myocardial infarction Hypoxia Infectious diseases Electrolyte imbalance Increased sympathetic tone Stimulants Drug toxicity, e.g., digoxin Stress Anxiety Coronary atherosclerosis Valvular disease; Cor pulmonale Pulmonary edema Myocardial infarction SA node disease Pulmonary embolism Digitalis toxicity ETOH abuse Postsurgical complication: one of the common dysrhythmias following open heart surgery. On rare occasions it may occur with normal healthy hearts. Acute myocardial infarction Left atrial stretch due to mitral stenosis and mitral regurgitation May be a chronic rhythm associated with heart failure Transient after open-heart surgery Long-standing hypertension Digoxin toxicity Alcohol intake, chronic or acute, moderate to heavy Idiopathic Physical Assessment Pulse: Irregular BP: If frequent PACs, may be decreased. If cardiac output is decreased the following clinical manifestations may occur: Angina Syncope Generalized weakness Dizziness Shortness of breath Altered mental state may be present, although rare. Pulse: May be regular or irregular BP: Lower than normal if cardiac output is decreased. If cardiac output is decreased the following clinical manifestations may occur: Angina Syncope Generalized weakness Dizziness Shortness of breath Altered mental state may be present, although rare. Pulse: Irregular (hallmark feature) BP: Lower than normal If cardiac output is decreased the following clinical manifestations may occur: Angina Syncope Generalized weakness Dizziness Shortness of breath Altered mental state may be present, depending on the ventricular rate. Pulse: Very fast. BP: Decreased if drop in cardiac output. If cardiac output is decreased the following clinical manifestations may occur: Angina Syncope Generalized weakness Dizziness Shortness of breath Altered mental state may be present, although rare. Treatment Observe the frequency of the PACs, and observe for decreased cardiac output (Chart 386). Treat the underlying cause, e.g., stress, anxiety, electrolyte imbalance. Frequent PACs or those that cause sustained tachycardia may require treatment with drugs that prolong atrial refractoriness, such as digoxin, verapamil, or propranolol.

Atrial flutter

Cardioversion is a common intervention. Drug therapy is used to reduce AV conduction: digitalis, propranolol, diltiazem. If a chronic situation the patient may be placed on anticoagulants like warfarin.

Atrial fibrillation

Control the ventricular response, i.e., heart rate. If a rapid ventricular response control with drugs: digoxin is still the drug of choice; betablockers (propranolol) and calcium channel blockers (verapamil, diltiazem). Calcium channel blockers work the fastest, and are the drug of choice when medically unstable. Prevent thromboembolic events with anticoagulant therapy, e.g., warfarin, Cardioversion: Is used if new onset, especially when hemodynamic instability is present. If successful, digoxin is used to prevent reoccurrence. It is necessary to find and treat the cause, e.g., stress, hypokalemia. Vagal maneuvers, i.e., bearing down, coughing, and carotid artery massage. Specific treatment may include: oxygen therapy and cardioversion. Drug therapy: adenosine is used to briefly terminate the rhythm for differential diagnosis. Verapamil is a calcium channel blocker; decreases heart rate. Cardioversion is performed if drug therapy and vagal maneuvers are unsuccessful.

Heart disease Supraventricular Rheumatic heart disease tachycardia includes paroxysmal Atrioventricular Coronary artery disease (CAD) node reentry tachycardia Hypoxia May be precipitated by a AVNRT premature atrial contraction (PAC) Atrial tachycardia May occur in healthy adults from a variety of causes: Overexertion Stress Excessive use of stimulants Smoking Hypokalemia

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CHART 387
Dysrhythmia

Atrial Dysrhythmias: Etiology, Physical Assessment, and TreatmentContinued

Etiology Congenital in origin: twice as common in males, and occurs in 0.1 to 0.3% of the general population. Physical Assessment Pulse: Rapid. Frequent episodes of palpitations. BP: May be decreased due to fast heart rate. If cardiac output is decreased the following clinical manifestations may occur: Angina Syncope Generalized weakness Dizziness Shortness of breath Altered mental state may be present, although rare. Pulse: 4060 bpm BP: Lower than normal If cardiac output is decreased the following clinical manifestations may occur: Angina Syncope Generalized weakness Dizziness Shortness of breath Altered mental state may be present, although rare. Pulse: Bradycardia that alternates with tachycardia, referred to as brady-tachy syndrome. BP: May decrease due to decreased cardiac output. If cardiac output is decreased the following clinical manifestations may occur: Angina Syncope Generalized weakness Dizziness Shortness of breath Altered mental state may be present, although rare. Treatment Same as that for supraventricular tachycardia. Radiofrequency ablation to terminate the accessory pathway.

Wolff-Parkinson-White (WPW) syndrome

Wandering atrial pacemaker

Frequently seen in normal individuals and is of no consequence. Digoxin toxicity

Treat only if symptomatic. Treatment typically is instituted when syncope and/or alteration in consciousness occurs. Attempt to identify and treat the cause. Administer oxygen. Establish IV access Drug therapy: Atropine Evaluate for transcutaneous or permanent pacemaker depending on impact on cardiac output

Sick sinus syndrome

Coronary artery disease Drugs: Cardiac glycoside, Antihypertensive agents, Calcium channel blockers Frequently, intermittent and unpredictable, may occur in the absence of heart disease Myocardial infarction Inflammatory or degenerative processes

Clinical manifestations and ECG findings determine treatment. Anticoagulants are used because of blood stasis if atrial flutter/fibrillation is present. The only definitive treatment is a permanent pacemaker to replace the SA node.