It is an atrial arrhythmia where uniform activation is

replaced by chaos, such that coordinated contractile function is lost and the atria dilate Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia with a prevalence of 0.5%1% in the general population but 10-fold greater in those aged over 65. It is characterized by an ECG lacking consistent P waves and a rapid, often irregular ventricular rate.

Classification

All episodes of AF lasting >30 seconds should be described as follows: First detected or a recurrent episode Self terminating or not self terminating Symptomatic or asymptomatic Paroxysmal (if self-terminating within 7 days) Persistent (prolonged episode that can be terminated by electrical or chemical cardioversion) Permanent (if it does not terminate or relapses within 24 hours of cardioversion) Lone (in the absence of underlying structural heart disease) or idiopathic (in the absence of any disease)

CAUSES Common
Hypertension Left ventricular failure (any cause) Coronary artery disease Mitral or tricuspid valve disease HCM COPD

Potentially reversible Alcohol binge Hyperthyroidism Acute MI Acute pericarditis Myocarditis Exacerbation of pulmonary disease Pulmonary embolism Cardiac surgery Congenital heart disease

Rare Autonomic vagal overactivity Pericardial effusion Cardiac metastases Myocardial infi ltrative diseases (e.g., amyloid) Atrial myxoma

Symptoms

Palpitations, dyspnea, fatigue, presyncope, syncope, and chest pains are common. ***However, 30% of patients present with AF as an incidental finding only. Ambulatory monitoring reveals that even patients with symptomatic paroxysmal AF have many asymptomatic episodes.

Signs
-Physical findings are an irregular pulse (which, if rapid, will be faster at the apex than wrist) -Variable intensity of the first heart sound -Absent a-waves in the JVP.

Atrial fibrillation: evaluation

A reversible cause should be sought early to allow appropriate treatment. The most important investigations are the following: ECG: irregular ventricular rate and absence of P waves. CXR: cardiomegaly, pulmonary edema, intrathoracic precipitant, valve calcification (MS) Chemistries: hypokalemia, renal impairment; check Mg2+, Ca2+ Cardiac enzymes: ?MI. Small rise after DC shock Thyroid function: thyrotoxicosis may present as AF only. Liver function tests Drug levels: especially if patient is taking digoxin Arterial blood gas (ABG): if hypoxic, in shock or ?acidotic Echocardiogram (TTE TEE): for LV function, valve lesions, and pericardial effusion, and to exclude intracardiac thrombus prior to conversion to SR. LA size is an important predictor of likely future maintenance of SR. Other investigations depend on suspected precipitant. Eg 24-hour ambulatory monitor, exercise testing (or other ischemia stress test), and coronary angiography can also be used.

Atrial fibrillation: management

A rate or rhythm control strategy Rate control Drugs The first-line agents are B-blockers or nondihydropyridine calciumchannel antagonists (verapamil or diltiazem), which are effective during both exercise and rest. Digoxin is effective only at rest and should be considered a second-line agent.

 Rhythm control

If symptoms are not improved by rate control alone, the restoration and maintenance of SR should be attempted. The trials of rate vs. rhythm control underrepresent younger patients (<65 years old), so in this group an aggressive strategy of rhythm control may be warranted regardless of symptoms. Drugs Flecainide, sotalol, dofetililide, propafenone, disopyramide, and quinidine are more effective than placebo in maintaining SR.

Pacemakers While various pacemaker strategies are hypothesized to be useful in maintaining SR, the data are limited. Atrial pacing modes (AAI or DDD) are preferable to reduce the AF burden.

Atrial defibrillators They are thought to work by promptly cardioverting each episode of AF, preventing remodeling of the atria. AF episodes may be reduced and quality of life may improve.However, even though shocks are low energy (12 J) they are painful.Careful patient selection is required, and current clinical use is limited. Catheter and surgical ablation Pace and ablate When adequate rate or symptom control is not possible with drugs or their side effects are not tolerated, a permanent pacemaker may be implanted followed by radiofrequency ablation of the AVN. This achieves rate control and therefore symptom improvement but renders the patient pacer dependent and should only be chosen as a last resort.

ANTICOAGULATION

Both aspirin (325 mg daily) and warfarin (INR 2 -3) reduce strokes in AF. Decisions regarding anticoagulation strategy depend on the patients overall stroke risk, and no distinction should be made between paroxysmal, persistent or permanent AF.

CHADs2
The CHADs score is a clinical prediction tool used to

estimate the risk of stroke in nonvalvular atrial fibrillation.

C Congestive heart failure H A D S2 Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) Age 75 years Diabetes mellitus Prior Stroke or TIA or Thromboembolism 1 1 1 2 1

 The risk increases with the number of features

present. Those patients having two or more features are categorized as having moderate to high risk of stroke per year (4%/year), and it is suggested that they be maintained on warfarin therapy. Those with one risk factor are at moderate risk (2.8%/year), and 0 are low risk

Emergency management
If the patient is hemodynamically compromised, then

urgent external synchronized DC cardioversion under general anesthesia or sedation is needed. This is rarely necessary; usually rate control is sufficient to acutely control symptoms

Thank you