Atrial Fibrillation: Difference between revisions

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[[File:Atrial_Fibrillation_TPMJM_BUDPT.png|right|528x528px]]
[[File:Atrial_Fibrillation_TPMJM_BUDPT.png|right|528x528px]]
Atrial fibrillation is the most common type of [[Heart Arrhythmias: Assessment|heart arrhythmia]]. It is due to abnormal electrical activity within the atria of the [[Anatomy of the Human Heart|heart]] causing them to fibrillate. Is characterized as a tachyarrhythmia ie the [[Heart Rate|heart rate]] is often fast. Due to its rhythm irregularity, blood flow through the heart becomes turbulent and has a high chance of forming a thrombus which can dislodge and embolize to the [[Brain Anatomy|brain]] and other parts of the body<ref name=":8">Nesheiwat Z, Jagtap M. [https://www.ncbi.nlm.nih.gov/books/NBK526072/ Rhythm, Atrial Fibrillation (A Fib).] InStatPearls [Internet] 2018 Oct 27. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526072/ (last accessed 11.1.2020)</ref>. 
Atrial fibrillation is the most common type of [[Heart Arrhythmias: Assessment|heart arrhythmia]]. It is due to abnormal electrical activity within the atria of the [[Anatomy of the Human Heart|heart]] causing them to fibrillate. Is characterized as a tachyarrhythmia ie the [[Heart Rate|heart rate]] is often fast. Due to its rhythm irregularity, blood flow through the heart becomes turbulent and has a high chance of forming a thrombus which can dislodge and embolize to the [[Brain Anatomy|brain]] and other parts of the body<ref name=":8">Nesheiwat Z, Jagtap M. [https://www.ncbi.nlm.nih.gov/books/NBK526072/ Rhythm, Atrial Fibrillation (A Fib).] InStatPearls [Internet] 2018 Oct 27. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526072/ (last accessed 11.1.2020)</ref>. 
Watch this 1 minute video on AF{{#ev:youtube|pgOHs3NTmIY}}


== Etiology ==
== Etiology ==
The risk of developing AF is substantially higher in elderly individuals. Common causes of AF include long-term high blood pressure, coronary heart disease and valvular heart disease. Other risks for AF include obesity, having a thyroid condition, diabetes, chronic kidney disease, obstructive sleep apnoea, and smoking or consuming alcohol excessively. For some people, there is no apparent cause.<ref>AIHW Atrial fibrillation in Australia Available:https://www.aihw.gov.au/reports/heart-stroke-vascular-diseases/atrial-fibrillation-in-australia/contents/what-is-atrial-fibrillation (accessed 3.2.2022)</ref>
The risk of developing AF is substantially higher in elderly individuals. Common causes of AF include long-term high blood pressure, coronary heart disease and valvular heart disease. Other risks for AF include obesity, having a thyroid condition, diabetes, chronic kidney disease, obstructive sleep apnoea, and smoking or consuming alcohol excessively. For some people, there is no apparent cause.<ref name=":0">AIHW Atrial fibrillation in Australia Available:https://www.aihw.gov.au/reports/heart-stroke-vascular-diseases/atrial-fibrillation-in-australia/contents/what-is-atrial-fibrillation (accessed 3.2.2022)</ref>


The 3 patterns of atrial fibrillation include:
The 3 patterns of atrial fibrillation include:
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== Pathophysiology ==
== 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.<ref name=":8" /><sup></sup>{{#ev:youtube|pgOHs3NTmIY}}
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.<ref name=":8" />
== Clinical Presentation ==
Often, people with AF do not know that they have it, and they do not experience any symptoms. Others may experience an irregular pulse, heart palpitations (‘fluttering’), fatigue, weakness, discomfort, shortness of breath or dizziness.<ref name=":0" />


== <sup></sup>Characteristics/Clinical Presentation  ==
Atrial Fibrillation (AF) symptoms vary on the functional state of the heart, the location of the fibrillation, and may exist without symptoms.<ref name=":0">National Heart, Lung, and Blood Institute [Internet]. [Place Unknown]: U.S. Department of Health and Human Services; Atrial Fibrillation. [updated 2014 September 18; cited 2016 April 2]. Available from: http://www.nhlbi.nih.gov/health/health-topics/topics/af</ref><sup>,6</sup>&nbsp;Individuals are usually aware of the irregular heart action and may report feeling palpitations or sensations of fluttering, skipping and pounding. Other symptoms experienced can be inadequate blood flow which can cause feelings of dizziness, chest pain, fainting, dyspnea, pallor, fatigue, nervousness, and cyanosis. More than six palpitations occurring in a minute or prolonged repeated palpitations should be reported to the physician.<ref name=":4">Goodman CC, Snyder TE. Differential Diagnosis for Physical Therapists, Screening for Referral. 5th ed. St. Louis Saunders; 2012. p. 264-266.</ref>&nbsp;&nbsp;<sup></sup>Over time, palpitations may disappear as the arrhythmia becomes permanent; it may become asymptomatic. This is common in the elderly. Some patients experience symptoms only during paroxysmal AF, or only intermittently during sustained AF. An initial appearance of AF may be caused by an embolic complication or an exacerbation of heart failure. Most patients complain of palpitations, chest pain, dyspnea, fatigue, lightheadedness, or syncope. Further, frequent urination (Polyuria) may be associated with the release of atrial natriuretic peptide, particularly as episodes of AF begin or terminate.<ref name=":1">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol. 2006: 114(7): p. 257-354.</ref>
<sup></sup><sup></sup>An irregular pulse should raise the suspicion of AF. Patients may present initially with a transient ischemic attack (TIA) or ischemic stroke. Most patients experience asymptomatic episodes of arrhythmias before being diagnosed. Patients with mitral valve disease and heart failure often have a higher incidence of AF. Intermittent episodes of AF may progress in duration and frequency. &nbsp;Over time many patients may develop sustained AF. For a newly diagnosed patient of AF, reversible causes such as pulmonary embolism, hyperthyroidism, pericarditis and MI should be investigated.<ref name=":5">Wadke R. Atrial Fibrillation. Disease-a-Month. 2013 March: 59(3): 67-73.</ref><sup></sup>
== Associated Co-morbidities  ==
== Associated Co-morbidities  ==


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*Hypertrophic obstructive cardiomyopathy  
*Hypertrophic obstructive cardiomyopathy  
*Dilated cardiomyopathy
*Dilated cardiomyopathy
*Atrial septal defect <ref name=":1" /><ref name=":4" /><ref name=":5" /><ref name=":6">Oishi ML, Xing S. Atrial fibrillation: Management strategies in the emergency department. Emerg Med Prac. 2013: 15(2): p. 1-26.</ref><ref name=":7">Gami AS, Hodge DO, Herges RM, Olson EJ, Nykodym J Kara T, Somers VK. Obstructive Sleep Apnea, Obesity, and the Risk of Incident Atrial Fibrillation. J Am Coll Cardiol [Internet]. 2007 Feb [cited 2016 April 9]; 49(5): 565-571. Available from: http://content.onlinejacc.org/article.aspx?articleid=1188673&amp;...#tab1</ref><sup><br></sup>
*Atrial septal defect <ref name=":1">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol. 2006: 114(7): p. 257-354.</ref><ref name=":4">Goodman CC, Snyder TE. Differential Diagnosis for Physical Therapists, Screening for Referral. 5th ed. St. Louis Saunders; 2012. p. 264-266.</ref><ref name=":5">Wadke R. Atrial Fibrillation. Disease-a-Month. 2013 March: 59(3): 67-73.</ref><ref name=":6">Oishi ML, Xing S. Atrial fibrillation: Management strategies in the emergency department. Emerg Med Prac. 2013: 15(2): p. 1-26.</ref><ref name=":7">Gami AS, Hodge DO, Herges RM, Olson EJ, Nykodym J Kara T, Somers VK. Obstructive Sleep Apnea, Obesity, and the Risk of Incident Atrial Fibrillation. J Am Coll Cardiol [Internet]. 2007 Feb [cited 2016 April 9]; 49(5): 565-571. Available from: http://content.onlinejacc.org/article.aspx?articleid=1188673&amp;...#tab1</ref><sup></sup>
 
 
== Medications  ==
 
<u>'''Rate control'''</u> (The typical approach to treating Atrial Fibrillation)
 
<u>[[Beta-Blockers|Beta-Blockers]]</u>
 
*Metoprolol CR/XL(Toprol XL)
*Bisoprolol (Zebeta)
*Atenolol (Tenormin)
*Esmolol (Brevibloc)
*Propranolol (Inderal)
*Carvedilol (Coreg)
 
<u>[[ACE Inhibitors in the Treatment of Congestive Heart Failure|Antihypertensive and calcium channel blocker]]</u>
 
*Verapamil (Calan)
*Diltiazem (Cardizem)
 
<u>Antiarrhythmic and blood pressure support</u>
 
*Digoxin (Lanoxin)
*Antiarrhythmic
*Amiodarone (Cordarone)
*Dronedarone (Multaq)
 
'''<u>Rhythm control</u>'''
 
<u>Antiarrhythmic</u>
 
*Amiodarone(Cordarone)
*Flecainide (Tambocor)
*Propafenone(Rythmol)
*Sotalol(Betapace)
 
Meds such as anticoagulants (commonly used along side these medications due to AF causing stroke) can cause brain hemorrhage. Benefits must be closely monitored.<ref name=":5" /><sup></sup>
== Diagnostic Tests/Lab Tests/Lab Values  ==
== Diagnostic Tests/Lab Tests/Lab Values  ==


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Changes in an individual's health such as a newly diagnosed complication may have a psychological impact. Patients may experience [[depression]] and other psycho-social challenges as a result of changes in their health status, treatment, frequent visits to the physician's office, and fear of the unknown that may accompany a diagnosis of atrial fibrillation.
Changes in an individual's health such as a newly diagnosed complication may have a psychological impact. Patients may experience [[depression]] and other psycho-social challenges as a result of changes in their health status, treatment, frequent visits to the physician's office, and fear of the unknown that may accompany a diagnosis of atrial fibrillation.


== Medical Management ==
== Management ==
Rate control and rhythm control through medications
Treatment strategy in recently diagnosed cases of atrial fibrillation includes identification and solution of reversible risk factors with anticoagulation therapy followed by beta-blockers.<ref>Radiopedia AF Available: https://radiopaedia.org/articles/atrial-fibrillation?lang=us<nowiki/>(accessed 3,3.2022)</ref>
**Studies have demonstrated that a rate control strategy, with a target resting heart rate between 80 and 100 beats/minute, is recommended over rhythm control in the vast majority of patients.
 
Non-pharmacological therapy includes ablation therapy, a hospital procedure which inactivates small areas of tissue in the heart responsible for the abnormal electrical signals associated with AF.  [[Cardiac Implantable Electronic Devices (CIEDs)|Pacemaker placement]] is considered in severe causes resulting in heart failure in atrial fibrillation<ref name=":8" />.


*Catheter ablation
People with prolonged or severe AF may undergo [[cardioversion]]. Pharmacological cardioversion uses medicines to achieve the same purpose. After cardioversion, long-term medicines are often prescribed to help prevent AF from reoccurring<ref name=":0" />.
*Atrioventricular node ablation
*Surgical maze procedure
*Thromboembolism Prevention<ref name=":1" /><ref name=":4" /><ref name=":5" />


== Physical Therapy Management  ==
== Physical Therapy Management  ==


There is limited research on the effect of traditional physical therapy and Atrial Fibrillation.&nbsp;<br>There is also conflicting information on the use of exercise to reduce the risk of AF. &nbsp;Since obesity is an important risk factor, management of weight through exercise and education is a crucial, proactive measure that may reduce the incidence of AF. However, there is conflicting evidence in regard to the optimal prescription of exercise.&nbsp;
There is limited research on the effect of traditional physical therapy and Atrial Fibrillation.&nbsp;<br>There is also conflicting information on the use of exercise to reduce the risk of AF. &nbsp;Since obesity is an important risk factor, management of weight through exercise and education is a crucial, proactive measure that may reduce the incidence of AF. However, there is conflicting evidence in regard to the optimal prescription of exercise.&nbsp;<br>
 
== Differential Diagnosis  ==
 
*Atrial tachycardia
*Atrial flutter with variable AV block
*Frequent atrial ectopies
*[[Pulmonary Embolism]]
*[[Hyperthyroidism]]
*Pericarditis
*[[Myocardial Infarction]]&nbsp;<ref name=":3" /><ref name=":4" /><ref name=":6" /><br>


== Case Reports/ Case Studies  ==
== Case Reports/ Case Studies  ==

Revision as of 02:37, 3 March 2022

Original Editors - Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.
Top Contributors - Paul McDermott, James Moore, Lucinda hampton, Kim Jackson, Adam Vallely Farrell, Elaine Lonnemann, George Prudden, WikiSysop, Karen Wilson and Vidya Acharya  

Introduction[edit | edit source]

Atrial Fibrillation TPMJM BUDPT.png

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 ie the heart rate is often fast. Due to its rhythm irregularity, blood flow through the heart becomes turbulent and has a high chance of forming a thrombus which can dislodge and embolize to the brain and other parts of the body[1]. 

Watch this 1 minute video on AF

Etiology[edit | edit source]

The risk of developing AF is substantially higher in elderly individuals. Common causes of AF include long-term high blood pressure, coronary heart disease and valvular heart disease. Other risks for AF include obesity, having a thyroid condition, diabetes, chronic kidney disease, obstructive sleep apnoea, and smoking or consuming alcohol excessively. For some people, there is no apparent cause.[2]

The 3 patterns of atrial fibrillation include:

  1. Paroxysmal AF: Here the episodes terminate spontaneously within 7 days.
  2. Persistent AF: The episodes last more than 7 days and often require electrical or pharmacological interventions to terminate the rhythm
  3. Long-standing persistent AD: rhythm that has persisted for more than 12 months, either because a pharmacological intervention has not been tried or cardioversion has failed.[1].

Epidemiology/Prevalence[edit | edit source]

The prevalence of atrial fibrillation has been increasing worldwide. It is known that the prevalence of atrial fibrillation generally increases with age. At the age of 80, the lifetime risk of developing atrial fibrillation jumps to 22%.[3]

Pathophysiology[edit | edit source]

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.[1]

Clinical Presentation[edit | edit source]

Often, people with AF do not know that they have it, and they do not experience any symptoms. Others may experience an irregular pulse, heart palpitations (‘fluttering’), fatigue, weakness, discomfort, shortness of breath or dizziness.[2]

Associated Co-morbidities[edit | edit source]

Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]

  • 12 lead EKG
    • Presence of low-amplitude fibrillatory waves on ECG without defined P-waves 2. Irregularly irregular ventricular rhythm 3. Fibrillatory waves typically have a rate of > 300 beats per minute 4. Ventricular rate is typically between 100 and 160 beats per minute. 
  • Holter monitor
  • Event recorder
  • Blood test
  • Stress tests
  • Chest X-ray
  • LV Hypertrophy
  • 6 minute walk test
  • Physical Exam: Irregular pulse, irregular jugular venous pulsations, variation in the intensity of first heart sound.[4][9][5][6]

Systemic Involvement[edit | edit source]

High concentrations of CRP in the blood test, which confirm the presence of systemic inflammation are present in people with Atrial Fibrillation (AF).[4]

Changes in an individual's health such as a newly diagnosed complication may have a psychological impact. Patients may experience depression and other psycho-social challenges as a result of changes in their health status, treatment, frequent visits to the physician's office, and fear of the unknown that may accompany a diagnosis of atrial fibrillation.

Management[edit | edit source]

Treatment strategy in recently diagnosed cases of atrial fibrillation includes identification and solution of reversible risk factors with anticoagulation therapy followed by beta-blockers.[10]

Non-pharmacological therapy includes ablation therapy, a hospital procedure which inactivates small areas of tissue in the heart responsible for the abnormal electrical signals associated with AF. Pacemaker placement is considered in severe causes resulting in heart failure in atrial fibrillation[1].

People with prolonged or severe AF may undergo cardioversion. Pharmacological cardioversion uses medicines to achieve the same purpose. After cardioversion, long-term medicines are often prescribed to help prevent AF from reoccurring[2].

Physical Therapy Management[edit | edit source]

There is limited research on the effect of traditional physical therapy and Atrial Fibrillation. 
There is also conflicting information on the use of exercise to reduce the risk of AF.  Since obesity is an important risk factor, management of weight through exercise and education is a crucial, proactive measure that may reduce the incidence of AF. However, there is conflicting evidence in regard to the optimal prescription of exercise. 

Case Reports/ Case Studies[edit | edit source]

1. Hwang KO. Case Study: Acute and Long-term Management of Atrial Fibrillation. MedPage Today. 2015. Available from: MedPage Today.
2. Ezekowitz MD, Aikens TH, Nagarakanti R, Shapiro T. Atrial fibrillation: outpatient presentation and management. Circulation. 2011; 124: 95–99. Available from: American Heart Association.
3. Peake ST, Mehta PA, Dubrey SW. Atrial fibrillation-related cardiomyopathy: a case report. Journal of Medical Case Reports. 2007;1:111. Available from: National Center for Biotechnology Information.

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Nesheiwat Z, Jagtap M. Rhythm, Atrial Fibrillation (A Fib). InStatPearls [Internet] 2018 Oct 27. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526072/ (last accessed 11.1.2020)
  2. ↑ 2.0 2.1 2.2 AIHW Atrial fibrillation in Australia Available:https://www.aihw.gov.au/reports/heart-stroke-vascular-diseases/atrial-fibrillation-in-australia/contents/what-is-atrial-fibrillation (accessed 3.2.2022)
  3. ↑ Atrial Fibrillation Fact Sheet [Internet]. Center for Disease Control and Prevention; 2013 [updated 2015 August 13; cited 2016 April 5] Available from: http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_atrial_fibrillation.htm
  4. ↑ 4.0 4.1 4.2 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol. 2006: 114(7): p. 257-354.
  5. ↑ 5.0 5.1 Goodman CC, Snyder TE. Differential Diagnosis for Physical Therapists, Screening for Referral. 5th ed. St. Louis Saunders; 2012. p. 264-266.
  6. ↑ 6.0 6.1 Wadke R. Atrial Fibrillation. Disease-a-Month. 2013 March: 59(3): 67-73.
  7. ↑ Oishi ML, Xing S. Atrial fibrillation: Management strategies in the emergency department. Emerg Med Prac. 2013: 15(2): p. 1-26.
  8. ↑ Gami AS, Hodge DO, Herges RM, Olson EJ, Nykodym J Kara T, Somers VK. Obstructive Sleep Apnea, Obesity, and the Risk of Incident Atrial Fibrillation. J Am Coll Cardiol [Internet]. 2007 Feb [cited 2016 April 9]; 49(5): 565-571. Available from: http://content.onlinejacc.org/article.aspx?articleid=1188673&...#tab1
  9. ↑ Amerena JV, Walters TE, Mirzaee S, Kalman JM. Update on the management of atrial fibrillation. Med J Aust. 2013: 199(9): p. 592-7.
  10. ↑ Radiopedia AF Available: https://radiopaedia.org/articles/atrial-fibrillation?lang=us(accessed 3,3.2022)
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