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Annamalai University

Department of General Medicine

Moderator Dr S.Sudharshan

Presentor-Dr M.Arun & Dr Varun s (M 5)



An arrhythmia is a problem with the rate or rhythm of the

Atrial fibrillation (AF) is the most common sustained
arrhythmia affecting humans.

It is marked by disorganized, rapid, and irregular atrial

Paroxysmal - AF that terminates
spontaneously within 7 days
Persistent AF that present continuously for
more than 7 days
Longstanding - AF persistent for more than 1
Permanent - AF refractory to cardioversion

Lone - AF that occurs in patients younger
than 60 years who do not have
hypertension or any evidence of
structural heart disease

Coronary heart disease


Mitral valve disease


Sick sinus syndrome

Congenital heart disease

Atrial septal defect
Ebstein's anomaly

Cardiac surgery




Lung disease

Electric shock
Lone (idiopathic)

Paroxysmal Pericarditis, Alcohol, Cardiac surgery

Persistent - Coronary heart disease, Cardiomyopathy,
Mitral valve disease, Congenital heart disease

Permanent Cardiomyopathy, Mitral valve disease,
Congenital heart disease

Mechanism of AF
Initiating event - a premature atrial or
ventricular complex.

Sustaining substrate - one or more Reentrant circuits or
Automatic Focus .

The initiating event and sustaining substrate may be all due to
automaticity or reentry circuit.
Automatic Focus
The drivers appear to originate predominantly from
the atrialized musculature that enters the pulmonary
veins and represent either focal abnormal
automaticity or triggered firing
Microreentry Circuits
Sustained forms of microreentry as drivers
also have been documented
around the orifice of pulmonary veins;
nonpulmonary vein drivers also have
been demonstrated.
Symptoms of Atrial Fibrillation
The symptoms of AF vary widely between patients,
ranging from none to severe and functionally
disabling symptoms

The most common symptoms of AF are palpitations,
fatigue, dyspnea, effort intolerance, and
lightheadedness. Polyuria can occur because of
release of atrial natriuretic hormone.

Syncope is an uncommon symptom of AF, most often
caused by a long sinus pause on termination of AF in
a patient with the sick sinus syndrome.
Asymptomatic or minimally symptomatic AF patients
are not prompted to seek medical care and can
present with a complication of AF such as stroke or

Physical examination
The hallmark of AF on physical examination is an irregularly
irregular pulse.

Short R-R intervals during AF do not allow adequate time for
left ventricular diastolic filling, resulting in a low stroke
volume and the absence of palpable peripheral pulse. This
results in a pulse deficit, during which the peripheral pulse is
not as rapid as the apical rate.

Other manifestations of AF on the physical examination are
irregular jugular venous pulsations and variable intensity of
the first heart sound.

Diagnostic Evaluation

Electrocardiographic Features
- Low-amplitude baseline oscillations (fibrillatory
or f waves)
- The f waves have a rate of 300 to 600 beats/min and
are variable in amplitude, shape, and timing.
- Irregularly irregular ventricular rhythm

- Atrial flutter (rate of 250 to 350 beats/min and are
constant in timing and morphology)

Comparison between the f waves of AF (top panel) and the
flutter waves of atrial flutter (bottom panel). f waves are variable
in rate, shape, and amplitude, whereas flutter waves are constant
in rate and all aspects of morphology.
A recording of AF with a rapid ventricular rate of 160 beats/min.
Shown are leads V
, II, and V
. On quick review, there may
appear to be a regular rate consistent with paroxysmal
supraventricular tachycardia. On closer inspection, it is clear that
the rate is irregularly irregular.
Holter recording
Patient who describes rapid palpitations suggestive of
paroxysmal AF, ambulatory monitoring is useful to
document whether AF is responsible for the symptoms

Evaluate atrial size and left ventricular function and to
look for left ventricular hypertrophy, congenital heart
disease & valvular heart disease

A stress test
Appropriate for evaluation of ischemic heart disease in
at-risk patients

Laboratory testing should include thyroid function tests, liver
function tests.

Therapy of Atrial Fibrillation: General
Three potential therapeutic goals of treatment

- Restoration and maintenance of sinus rhythm,

- Rate control during AF,

- Prevention of thromboembolism
Restore sinus rhythm or Ventricular rate
control ?

Decision should be individual to each patient, based on
analysis of the risk benefit ratio for that individual.

Factors to consider are
- Severity of symptoms,
- Left atrial size,
- Patient age,
- Presence of cardiovascular disease or other medical
- Pharmacologic and nonpharmacologic options
Severity of symptoms

- If patient is hemodynamically unstable or is in
severe cardiac failure, immediate
DC cardioversion aimed at restoring sinus rhythm
must be tried.

Left atrial size

- Patients with dilated left atrium are more prone to AF,
and these patients are more likely to remain in AF than
those with normal LA dimensions

- In these patients rate control is ideal
Patient age
For example, an elderly patient with minimal symptoms
and years of persistent AF is an ideal candidate for a
rate control and anticoagulation treatment strategy.
Alternatively, a young patient with very symptomatic
episodes of paroxysmal AF should be considered
initially for a rhythm control treatment strategy
Presence of cardiovascular disease or other medical

In patients with Permanent AF(Cardiomyopathy,
Mitral valve disease, Congenital heart disease) rate
control is preferred

The Atrial Fibrillation Follow-Up Investigation of Rhythm
Management (AFFIRM) trial was the largest trial which
compared difference in mortality between the rhythm and
rate control strategies in AF.

The mean follow-up in AFFIRM was 3.5 years; thus, only
short-term follow-up data are available.

There was no difference in mortality between the rhythm
and rate control strategies.

Thus, clinicians should individualize their approach and
select the treatment strategy that is best for each patient.
One important observation is that in patients at high risk for
stroke, long-term anticoagulation is required regardless of
whether a rhythm or rate control strategy is selected.
Two important decisions in acute AF
If cardioversion is decided on for a hemodynamically
stable patient who presents with AF that does not
appear to be self-limited, there are two management
decisions to be made: early versus delayed
cardioversion and pharmacologic versus electrical

Early or Delayed Cardioversion ?
Duration of AF

Duration < 48 hrs
- Less chance of thromboembolism
- No need for anticoagulant before
cardioversion(chemical or DC) to restore sinus rhythm

Duration > 48 hrs
- Transesophagial echocardiography to rule out
Atrial thrombus.
- If thrombus present- anticoagulant for 3 weeks
before Cardioversion (chemical or DC) and
4 weeks following cardioversion.

Chemical cardioversion or DC cardioversion
for restoring rhythm ?
Pharmacologic cardioversion has these advantage
- Does not requiring general anesthesia or deep

Disadvantages of pharmacological cardioversion
- Associated with the risk of adverse drug effects
- Not as effective as electrical cardioversion.
- Unlikely to be effective if the duration of AF is longer
than 7 days
DC cardioversion
Rhythm control
Rate control
< 48 hrs > 48 hrs
Rate control
3 weeks
before cardioversion
Start anticoagulant
and cardiovert
Intravenous Agents to Restore Sinus Rhythm
Commonly used drugs are Ibutalide(60-70%),
Amiodarone (40-50%), procainamide(30-40%).

To minimize the risk of QT prolongation and polymorphic
ventricular tachycardia (torsades de pointes ), the use of
ibutilide should be limited to patients with an ejection fraction

Other drugs which can be also used are flecainide,
propafenone, and sotalol.

Oral Antiarrhythmic Agents for Restoration of
sinus rhythm
Acute pharmacologic cardioversion of AF also can be
attempted with orally administered drugs in patients without
structural heart disease.

The most commonly used oral agents for acute conversion of
AF are propafenone (300 to 600 mg) and flecainide (100 to
200 mg).
Oral agents for Maintenance of Sinus Rhythm
All of the available drugs except amiodarone have similar
efficacy and are associated with a 50% to 60% reduction in the
odds of recurrent AF during 1 year of treatment

Lone AF or minimal heart disease - flecainide, propafenone,
sotalol, and dronedarone are reasonable first-line drugs, and
amiodarone and dofetilide can be considered if the first-line
agents are ineffective or not tolerated.

In patients with substantial left ventricular hypertrophy, the
hypertrophy may heighten the risk of ventricular
proarrhythmia, and the safest choice for drug therapy is

In patients with coronary artery disease, the safest first-line
options are dofetilide, sotalol, and dronedarone, with
amiodarone reserved for use as a second-line agent.

In patients with heart failure, several antiarrhythmic drugs
have been associated with increased mortality, and the only
two drugs known to have a neutral effect on survival are
amiodarone and dofetilide.
Drug having higher efficacy than the others is amiodarone.
However, because of the risk of organ toxicity, amiodarone is
not appropriate first-line drug therapy for most categories of
patients with AF.

Risk factors for proarrhythmia in patients on these drugs
include female gender, left ventricular dysfunction, and
Use of Drug Therapy to Control Ventricular
Drugs used to decrease conduction in the AV node are useful
in controlling ventricular rate in patients who have AF

It is very important to control ventricular rate, not only to
decrease symptoms, but also to prevent tachycardia-mediated
ventricular cardiomyopathy

Commenly used drugs are digitalis, beta blockers, calcium
channel antagonists, and amiodarone.
Beta blocker & Calcium channel blocker
-The first-line agents for rate control

- Preferred over digoxin for rate control in patients who
have not experienced heart failure.

- Adrenergic blockers are also recommended in
situations in which sympathetic tone is increased,
such as thyrotoxicosis

- Adequately control the rate at rest but often does not
provide adequate rate control during exertion.

- Its use is appropriate in patients with systolic heart


- Less frequently used for rate control than the other
agents because of the risk of organ toxicity
associated with long-term therapy.

- Amiodarone may be an appropriate choice for rate
control if the other agents are not tolerated or are
Rate control in WPW syndrome
Use of agents that depress conduction over the accessory

In the acute setting, intravenous procainamide and ibutilide
are the treatments of choice, unless the patient is unstable and
requires urgent electrical cardioversion.

The use of drugs such as digoxin, calcium channel blockers,
adrenergic blockers, and adenosine are contraindicated in this
situation as they do not block conduction over the accessory
pathway and may accelerate the ventricular response
Transthoracic Electrical Cardioversion
Many patient who has AF may be a candidate for transthoracic
DC cardioversion.

Certain characteristics predict poor success in maintenance of
sinus rhythm
- Mitral valve disease
- Very large left atrium
- Patients who have AF of relatively long duration

Antiarrhythmic drugs are frequently used to maintain sinus
rhythm in patients undergoing transthoracic direct current
(DC) cardioversion.

Drug therapy should be considered before use of
cardioversion in patients with long-standing AF (e.g., >3
months), to lessen the chance of early recurrence of AF in the
first few days after cardioversion
Prevention of Thromboembolism
Prevention of stroke is key to the management of the condition
of patients with AF

warfarin is highly effective in reducing the incidence of
ischemic stroke among patients with AF . Overall, a combined
risk reduction of 68% is seen.

Aspirin does not prevent thromboembolic complications as
effectively as warfarin in patients with AF

Catheter Ablation
Success rates of more than 95% are attainable when the
arrhythmia substrate is well defined, localized, and temporally

In contrast, the arrhythmia substrate of AF as yet is not well
understood, usually is widespread, is variable between patients,
and may be progressive.

AF may recur more than 2 or 3 years after an initially
successful ablation procedure.
Indications for catheter ablation

- Young patients(< 35 yrs) with symptomatic AF that is
affecting quality of life and that has not adequately
responded to drug therapy.
- The ideal candidate has lone AF or only minimal
structural heart disease(such as normal left atrial size)
- Patients with sinus node dysfunction in whom
antiarrhythmic drug therapy is likely to create the need
for a permanent pacemaker.

Surgical Approaches to Atrial Fibrillation
The most effective surgical procedure for AF is the cut-and-
sew maze procedure developed by Cox in 1987.

This operation involves 12 atrial incisions to isolate the
pulmonary veins and to create lines of block in the left atrium
and right atrium.

In addition, the left and right atria are excised.

Long-term freedom from AF after the Cox maze procedure has
been reported to range from 70% to 95%, but 10% to 35% of
patients still require antiarrhythmic drug therapy
The Cox maze procedure has not been widely performed
because it requires cardiopulmonary bypass, is technically
difficult, and is associated with a mortality risk of
approximately 1% to 2%.

Braunwald's Heart Disease, 9th Edition.

Topol Textbook of Cardiovascular Medicine, 3rd Edition.

Harrison's Principles of Internal Medicine, 18th Edition.
Annamalai university