ecg: new onset af with slow ventricular response
TRANSCRIPT
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ECG OF THE WEEKProf.Dr.P.Vijayaraghavan’s unit
Dr.C.R.Rajkumar
M6 unit
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65 year old lady presented with breathlessness to the OPD.
No significant past history. On Examination:
Pulse was irregularly irregular, varying in volume. Rate – 50/min, Pulse deficit 11/min. BP – 110/70 CVS – S1 varying in intensity. No murmurs.
ECG was taken.
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ECG SHOWS
Ventricular Rate of 60/min Varying RR interval QRS Axis 35 QRS Duration 100ms QRS morphology normal, occasional artifacts No ST segment T wave changes Absent P waves Undulating baseline
.
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DIAGNOSIS
New onset Atrial Fibrillation with slow ventricular response
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DD FOR AF WITH SLOW VENTRICULAR RESPONSE:
1) High vagal tone2) AF with associated AV heart block3) Digoxin effect4) Beta blocker and other drugs
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ATRIAL FIBRILLATION The most common sustained cardiac rhythm
disturbance
Def: Supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of atrial mechanical function.
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MECHANISM Atrial factors: Enhanced automaticity in 1 or several rapidly
depolarizing foci and reentry involving 1 or more circuits.
The multiple-wavelet hypothesis: that fractionation of the wave fronts as they propagate through the atria results in self-perpetuating “daughter wavelets
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CLASSIFICATION: First onset AF: whether or not it is
symptomatic or self-limited, recognizing that there can be uncertainty about the duration of the episode and about previous undetected episodes
Recurrent AF : (1) Paroxysmal AF (self terminating, episodes
<7 days) (2) Persistent AF (not self terminating usually
greater than 7 days) (3) Permanent AF (cardio version failed or not
attempted)
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MYOCARDIAL AND HEMODYNAMIC CONSEQUENCES 3 factors affect hemodynamic function: loss of synchronous atrial mechanical
activity. Irregularity of ventricular response. Inappropriately rapid heart rate
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MYOCARDIAL AND HEMODYNAMIC CONSEQUENCES A persistently rapid atrial rate can adversely
affect atrial mechanical function (tachycardia-induced atrial cardiomyopathy)
A persistently elevated ventricular rate during AF can produce dilated ventricular cardiomyopathy.
HF can be the initial manifestation of AF
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COMMON CAUSES 10% elderly, more than 75 yrs Lone AF less than 65 yrs Valvular heart disease Hypertension Myocarditis and cardiomyopathy Cardiac surgery Hyperthyroidism Alcohol poisoning Autonomic dysfunction SVT Sick sinus syndrome
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CLINICAL MANIFESTATIONS
Symptoms vary with the ventricular rate, underlying functional status, duration of AF and individual patient perceptions.
Most patients with AF complain of palpitations, chest pain, dyspnea, fatigue, or light headedness, polyuria, syncope.
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IF UNSTABLECardioversion
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IF STABLE1. Rate control 2. Minimize thrombo-embolic risk.3. Establish etiology4. Restore sinus rhythm5. Maintain sinus rhythm
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PLAN FOR THIS PATIENT:
In this patient since clinically it appears to be new onset fibrillation of more than 48 hrs duration, patient can be anti-coagulated. Since clinically stable, rate and rhythm control are of secondary importance.
Echo to rule out structural heart disease.TEE (Trans-Esophageal Echo) for LA clot.
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