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Atrial Fibrillation: Diagnosis and Treatment CECILIA GUTIERREZ, MD, and DANIEL G Atrial Fibrillation: Diagnosis and Treatment CECILIA GUTIERREZ, MD, and DANIEL G. BLANCHARD, MD, University of California, San Diego, La Jolla, California Atrial fibrillation is the most common cardiac arrhythmia. It impairs cardiac function and increases the risk of stroke. The incidence of atrial fibrillation increases with age. Key treatment issues include deciding when to restore normal sinus rhythm, when to control rate only, and how to prevent thromboembolism. Rate control is the preferred manage- ment option in most patients. Rhythm control is an option for patients in whom rate control cannot be achieved or who have persistent symptoms despite rate control. The current recommendation for strict rate control is a resting heart rate of less than 80 beats per minute. However, one study has shown that more lenient rate control of less than 110 beats per minute while at rest was not inferior to strict rate control in preventing cardiac death, heart failure, stroke, and life- threatening arrhythmias. Anticoagulation therapy is needed with rate control and rhythm control to prevent stroke. Warfarin is superior to aspirin and clopidogrel in preventing stroke despite its narrow therapeutic range and increased risk of bleeding. Tools that predict the risk of stroke (e.g., CHADS2) and the risk of bleeding (e.g., Outpatient Bleed- ing Risk Index) are helpful in making decisions about anticoagulation therapy. Surgical options for atrial fibrillation include disruption of abnormal conduction pathways in the atria, and obliteration of the left atrial appendage. Catheter ablation is an option for restoring normal sinus rhythm in patients with paroxysmal atrial fibrillation and normal left atrial size. Referral to a cardiologist is warranted in patients who have complex cardiac disease; who are symptomatic on or unable to tolerate pharmacologic rate control; or who may be candidates for ablation or surgical interventions. (Am Fam Physician. 2011;83(1):61-68. Copyright © 2011 American Academy of Family Physicians.) ▲ Patient information: trial fibrillation is the most common independent risk factor for mortality 6,7; it A handout on atrial fibril- cardiac arrhythmia, and its inci- can also lead to or worsen heart failure and lation, written by the 1,2 authors of this article, is dence increases with age. It increase mortality rates in patients who have 8,9 provided on page 71. affects about 1 percent of patients had myocardial infarction. Ayounger than 60 years and about 8 per- cent of patients older than 80 years.3 Atrial Pathophysiology fibrillation is defined as a supraventricular Two mechanisms have been identified in tachyarrhythmia characterized by uncoor- triggering and maintaining atrial fibrilla- dinated atrial activation with consequent tion: enhanced automaticity in one or more deterioration of mechanical atrial func- depolarizing foci, and reentry involving one tion.4 Electrocardiographic findings include or more aberrant circuits. If it persists, atrial the replacement of the normal consistent fibrillation can cause atrial remodeling, P waves (which represent synchronous atrial which is characterized by patchy fibrosis; activation) with oscillatory or fibrillatory abnormal and excessive deposition of colla- waves of different sizes, amplitudes, and gen; fatty infiltration of the sinoatrial node; timing (Figure 1). The QRS complex remains molecular changes in ion channels; changes narrow unless other conduction abnormali- in depolarization pattern and cellular energy ties exist (e.g., bundle branch block, acces- use; and apoptosis.10,11 Chronic remodeling sory pathways). The ventricular response is leads to irreversible atrial enlargement. The often rapid, between 90 and 170 beats per longer the heart remains in atrial fibrillation, minute. the more difficult it is to restore normal sinus Atrial fibrillation is a source of significant rhythm. After a critical point is reached, par- morbidity and mortality because it impairs oxysmal atrial fibrillation self-perpetuates cardiac function and increases the risk of and becomes persistent.10,11 stroke. Its most important clinical impli- cations are shown in Figure 2. The cost of Definitions caring for patients with atrial fibrillation Different types of atrial fibrillation have dif- is about five times greater than caring for ferent prognoses, morbidity rates, mortal- patients without it.5 Atrial fibrillation is an ity rates, and treatment options (Table 1).4 Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2010 American Academy of Family Physicians. For the private, noncommercial January 1,use 2011 of one ◆ Volumeindividual 83, user Number of the Web 1 site. All other rights reserved.www.aafp.org/afp Contact [email protected] for copyright questionsAmerican and/or permission Family requests. Physician 61 Figure 1. Electrocardiogram showing atrial fibrillation. P waves are absent and replaced by irregular electrical activity. The ventricular rate is irregular and chaotic. For example, valvular atrial fibrillation, which is caused cardiac and thoracic surgery. It is usually self-limited, by structural changes in the mitral valve or congeni- but should be treated aggressively if it persists because tal heart disease, carries the highest risk of stroke (i.e., of the increased risk of stroke. Lone atrial fibrillation 17 times that of the general population and five times occurs in patients younger than 60 years who have no the risk of stroke with nonvalvular atrial fibrillation).6 underlying cardiac disease and no identifiable cause. Secondary atrial fibrillation is caused by an underlying The prognosis is very good in patients with lone atrial condition and is reversible if the condition is treated. fibrillation. Paroxysmal atrial fibrillation refers to epi- The most common underlying conditions are listed in sodes of intermittent atrial fibrillation that terminate Table 2. Atrial fibrillation may occur immediately after spontaneously. Chronic atrial fibrillation is continu- ous and either cannot be converted back to normal sinus rhythm or a decision has Clinical Implications of Atrial Fibrillation been made not to attempt cardioversion. Persistent atrial fibrillation does not self- Loss of coordinated atrial contraction terminate, but may be terminated by electri- cal or pharmacologic cardioversion. Clinical Presentation Rapid ventricular response Decreased diastolic filling Blood stasis and atrial clot formation Atrial fibrillation has a wide spectrum of clinical presentations. Some patients may Tachycardia be asymptomatic. Others may present with Decreased cardiac output Shorter diastolic fill time stroke, overt heart failure, or cardiovascu- Reduced coronary circulation lar collapse. Patients most commonly report and possible ischemia Thromboembolism palpitations, dyspnea, fatigue, lighthead- Tachycardia-mediated cardiomyopathy edness, and chest pain. Because symptoms Increased stroke risk are nonspecific, they cannot be used to diagnose and determine the onset of atrial fibrillation.4 If electrocardiography does not Increased morbidity and mortality demonstrate atrial fibrillation and a strong suspicion persists, a Holter or cardiac event monitor may be needed to document the Figure 2. Flowchart for clinical implications of atrial fibrillation. arrhythmia. 62 American Family Physician www.aafp.org/afp Volume 83, Number 1 ◆ January 1, 2011 Atrial Fibrillation Table 1. Classification of Atrial Fibrillation Table 3. Initial Evaluation of Atrial Fibrillation Type of atrial Test Purpose fibrillation Characteristics Chest radiography Identify possible pulmonary disease Chronic/ Continuous atrial fibrillation that (e.g., pneumonia, vascular permanent is unresponsive to cardioversion; congestion, chronic obstructive cardioversion will not be reattempted pulmonary disease) Lone Occurs in persons younger than Complete blood Identify comorbid conditions 60 years and in whom no clinical or count (e.g., anemia, infection) echocardiographic causes are found Complete Identify electrolyte abnormalities Nonvalvular Not caused by valvular disease, prosthetic metabolic profile that may cause or exacerbate atrial heart valves, or valve repair fibrillation Paroxysmal Episodes that terminate spontaneously Assess kidney and liver function and Persistent Paroxysmal atrial fibrillation sustained for blood glucose level more than seven days, or atrial fibrillation Echocardiography Assess heart size and shape; chamber that terminates only with cardioversion sizes and pressures; valve structure Recurrent Two or more episodes of atrial fibrillation and function; presence of pericardial Secondary Caused by a separate underlying condition effusion; wall motion abnormalities; or event (e.g., myocardial infarction, systolic and diastolic function cardiac surgery, pulmonary disease, Electrocardiography Diagnose atrial fibrillation and hyperthyroidism) identify other arrhythmia (e.g., atrial flutter, atrial tachycardia) Information from reference 4. Identify other cardiac conditions (e.g., left ventricular hypertrophy, ischemia, strain, injury) Thyroid-stimulating Identify hyperthyroidism hormone Table 2. Secondary Causes of Atrial Fibrillation measurement Cardiac Cardiothoracic surgery examination, and diagnostic testing should focus on Congenital heart disease potential causes, triggers, and comorbid conditions. Stan- Heart failure dard tests used to evaluate cardiac function and identify Infiltrative disease (e.g., amyloid heart disease) common comorbid conditions
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