Overview + Definitions
- Most common arrhythmia
- Increased risk with age
- Irregularly, irregular rhythm and absent P waves on EKG
- Valvular vs. non-valvular (valvular means that arrhythmia is being caused by some type of valve disease ie rheumatic fever or from a defect in a prosthetic valve) Most cases are non-valvular A-Fib (you will hear that term frequently!)
- A-Fib w/ RVR (stands for “rapid ventricular response”): This basically means that the person is not in rate controlled A-Fib and the ventricles are trying to keep up with all the beats being initiated by the atria.
- The more days/weeks A-Fib persists the increasing likelihood that it will be permanent
- Paroxysmal A-Fib: Self-terminating within 7 days onset. Usually terminates <48 hours. Recurs with variable frequency.
- Persistent A-Fib: Atrial fibrillation that fails to self-terminate within 7 days or requires medication for termination.
- Permanent: Has persisted >12 months and cardioversion has usually been unsuccessful. Focus shifts to rate control
Etiology + Risk Factors
- Coronary Artery Disease
- Congestive Heart Failure
- Acute Coronary Syndrome
- Pulmonary Disease (esp COPD flares)
- Etoh (“Holiday Heart”) –> Lots of patients will show up to the hospital around the holidays because of increase of alcohol use
- Surgery or anything that will cause fluid shifts in the body either overload or dehydration
- Has patient missed any doses of rate controlled medication?
- Palpitations/Chest Pain
- SOB (may have increased O2 requirement secondary to heart beating so fast patients are not perfusing appropriately and become SOB– once their HR slows the will perfuse better and O2 requirement likely subsides
- Troponin x3 + CKMB x1
- CT PE study (for rule out–in hospitalized patients who have a new oxygen requirement
- Telemetry Monitoring
Steps to take/Questions to ask:
- Calculate Cha2ds2 Vasc:
- The “chads vasc” is a scale that determines an individual’s risk per year for stroke. Based on their risk have a discussion with the patient about risks and benefits of oral anticoagulation
- Scale includes:
- Congestive Heart Failure
- Age (2pts) >75, (1 pt) >65
- Stroke/TIA history (2pts)
- Vascular Disease
- Sex (+1 if female)
- Is the patient rate controlled?
- New onset?
- If rate controlled determine need for oral anticoagulation (watch providing with elderly who fall frequently)
- If rate isn’t controlled do so with a BB
- Is the patient rate controlled? (<110 BPM)
- A-Fib RVR:
- In a hospitalized patient options for treatment include IV Lopressor (may repeat for 3 doses, Cardizem 5mg +/- drip (may also repeat), Digoxin or Amiodarone bolus +/- drip
- If low BP will want to hold off on Cardizem or Lopressor–cardizem will really drop the BP
- Amiodarone is my go to when a patients BP is low 150mg bolus followed by a drip of 1mg/kg x6 hours, .5mg/kg for 6 hours, 400mg daily and then 200mg daily for maintenance
- Are they hemodynamically stable?
Below is one of my favorite flow charts from UpToDate (love this source!) This is a really good place to start to understand the treatment of A-Fib
Prognosis + Complications
- The longer a person remains in atrial fibrillation the greater the risk it will be a permanent rhythm
- RVR (rapid ventricular response)
- Frequently seen in the hospital especially with CHF exacerbation, surgery (because of fluid shifts)
- Because of the irregular rhythm of the atria and valves individuals with a-fib are at increased risk of developing clots on their mitral valve and throwing ot through their aortic valve and to the brain
- Calculate chads vasc as above to determine risk
This is probably one of the vital mistakes I made in PA school. We had to choose within our first six months of didactic year and I was on the clueless train as to what area I wanted to practice. So, here is the advice I wish I knew when I chose my elective rotation.
1. Play the Numbers for the PANCE.
Yep this means Cardiology. Cards makes up 16% of content on the boards. It’s also a huge part of practice no matter what area you go in to, especially if you are practicing in any type of medicine. Learn everything you need to know about treating STEMI’s, NSTEMI’s, CHF and A-Fib.
2. Increase the Acuity
If you have any interest working in general medicine or in any specialty practicing in a hospital setting think about Critical Care. I realize that the more rapid responses I’m involved in and forced to handle critical patient situations the more I advance as a provider.
3. Future Job
Preceptors hire previous students, so think about what area of medicine you want to practice and where you might want to live. Try and get a rotation based on where you want to live, or even just experience in an area of medicine regardless of location. For example rotating in dermatology would give you an edge over an applicant who did not complete a rotation in dermatology.
4. Infectious Disease
Bugs and drugs people. Everyone needs to know about antibiotic coverage. I definitely wish I would have dug more into what antibiotics cover what types of bacteria in school. Although you probably don’t need a lot of this information for boards (you likely won’t get questions like what is the best drug to treat gram negative bacteria) it will help you when you graduate.
5. Once in a lifetime
Some people take the opportunity to learn an area of medicine you may never practice or experience again. For example neonatal medicine, maternal fetal medicine, specific area of oncology, pediatric neurosurgery, etc. You get the idea.