Atrial fibrillation maintenance of rate control and sinus rhythm

	Atrial Fibrillation Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Atrial Fibrillation from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Special Groups Postoperative AF Acute Myocardial Infarction Wolff-Parkinson-White Preexcitation Syndrome Hypertrophic Cardiomyopathy Hyperthyroidism Pulmonary Diseases Pregnancy ACS and/or PCI or valve intervention Heart failure
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram EKG Examples A-Fib with LBBB
Chest X Ray
Echocardiography
Holter Monitoring and Exercise Stress Testing
Cardiac MRI
Treatment
Rate and Rhythm Control
Cardioversion Overview Electrical Cardioversion Pharmacological Cardioversion
Anticoagulation Overview Warfarin Converting from or to Warfarin Converting from or to Parenteral Anticoagulants Dabigatran
Maintenance of Sinus Rhythm
Surgery Catheter Ablation AV Nodal Ablation Surgical Ablation Cardiac Surgery
Specific Patient Groups
Primary Prevention
Secondary Prevention
Supportive Trial Data
Cost-Effectiveness of Therapy
Case Studies
Case #1
Atrial fibrillation maintenance of rate control and sinus rhythm On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Atrial fibrillation maintenance of rate control and sinus rhythm
CDC on Atrial fibrillation maintenance of rate control and sinus rhythm
Atrial fibrillation maintenance of rate control and sinus rhythm in the news
Blogs on Atrial fibrillation maintenance of rate control and sinus rhythm
Directions to Hospitals Treating Atrial fibrillation maintenance of rate control and sinus rhythm
Risk calculators and risk factors for Atrial fibrillation maintenance of rate control and sinus rhythm

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Varun Kumar, M.B.B.S.

Overview

Maintenance of sinus rhythm could be reached by using anti-arrhythmic drug therapy in patients with atrial fibrillation and it is specially recommended in symptomatic patients. There are six anti-arrhythmic drugs recommended and available for sinus rhythm maintannace in atrial fibrillation (AF). Choosing the proper anti-arrhythmic drug based on patient's underlying diseases and possible side effects is critical. Moreover, all of the anti-arrhythmic drugs (AADs) should be discontinued if a patient's (atrial fibrillation (AF) becomes permanent. Catheter-based ablation is an alternative to anti-arrhythmic drugs (AADs) therapy that could be considered as a first-line option at experienced centers.

Maintenance of Sinus Rate

Lifestyle interventions

Wieght loss may help^[1].

Medications

Anti-arrhythmic drug therapy could be useful to maintain sinus rhythm in patients with atrial fibrillation. Although in general rhythm control does not produce better outcomes, compared to rate control in terms of stroke or mortality, it is still one of the main treatments. Nevertheless, a rhythm control approach may be favored if the patient is highly symptomatic, or hemodynamically unstable (often seen in congestive heart failure patients due to loss of the atrial kick in atrial fibrillation (AF)).
There are six anti-arrhythmic drugs (AADs) recommended for atrial fibrillation (AF).^[2]
- Flecainide and propafenone are class Ic anti-arrhythmics.
- Dofetilide, sotalol, dronedarone, and amiodarone are class III antiarrhythmics.
- Other anti-arrhythmic drugs (lidocaine, quinidine, etc) are not recommended.
- It is recommended to select anti-arrhythmic drugs (AADs), based on a patient's underlying heart issues (if any).
In patients with no structural heart disease (no CAD and no CHF), any of the six listed anti-arrhythmic drugs (AADs) is reasonable.
Given the toxicities of amiodarone and concerns about its long term use, amiodarone is not recommended for first-line therapy. It should be used only if other agents have failed or are contraindicated.^[2]^[3] It should be used only if other agents have failed or are contraindicated.
The class Ic AADs (flecainide and propafenone) are contraindicated in patients who are suffering from Coronary heart disease. Class Ic AADs have been found to cause increased death and cardiac arrest in patients post-MI.^[4]
Flecainide, propafenone, dofetilide, and sotalol are not recommended for patients with severe left ventricular hypertrophy (LVH).
In patients with CHF, amiodarone and dofetilide are recommended.
All of these drugs carry a risk of pro-arrhythmia. Dofetilide and sotalol particularly prolong the QT interval and increase risk of Torsade de pointes. Hence, these drugs must initiated in the hospital to allow for careful monitoring of the QT interval.
anti-arrhythmic drugs (AADs) therapy does not obviate the need for anticoagulation in atrial fibrillation patients.

Ablation

Catheter-based ablation is an alternative to anti-arrhythmic drugs (AADs) therapy that should be considered as a first-line option at experienced centers ^[2] per the 2014 AHA guidelines.
Surgical atrial fibrillation ablation can be considered if the patient needs cardiac surgery for another reason, or as a last recourse if other options have failed.
All of the anti-arrhythmic drugs (AADs) should be discontinued if a patient's (atrial fibrillation (AF) becomes permanent.

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)^[5]

Rhythm Control

Antiarrhythmic Drugs to Maintain Sinus Rhythm

Class I
"1. Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended. (Level of Evidence: C)"
"2. The following antiarrhythmic drugs are recommended in patients with AF to maintain sinus rhythm, depending on underlying heart disease and comorbidities: a. Amiodarone, b. Dofetilide, c. Dronedarone, d. Flecainide, e. Propafenone, f. Sotalol. (Level of Evidence: A)"
"3. The risks of the antiarrhythmic drug, including proarrhythmia, should be considered before initiating therapy with each drug. (Level of Evidence: C)"
"4. Owing to its potential toxicities, amiodarone should only be used after consideration of risks and when other agents have failed or are contraindicated. (Level of Evidence: C)"

Class III: Harm
"1. Antiarrhythmic drugs for rhythm control should not be continued when AF becomes permanent (Level of Evidence: C) including dronedarone. (Level of Evidence: B)"
"2. Dronedarone should not be used for treatment of AF in patients with New York Heart Association (NYHA) class III and IV HF or patients who have had an episode of decompensated HF in the past 4 weeks. (Level of Evidence: B)"

Class IIa
"1. A rhythm-control strategy with pharmacological therapy can be useful in patients with AF for the treatment of tachycardia-induced cardiomyopathy. (Level of Evidence: C)"

Class IIb
"1. It may be reasonable to continue current antiarrhythmic drug therapy in the setting of infrequent, well-tolerated recurrences of AF, when the drug has reduced the frequency or symptoms of AF. (Level of Evidence: C)"

AF Catheter Ablation to Maintain Sinus Rhythm

Class I
"1. AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm control strategy is desired. (Level of Evidence: A)"
"2. Prior to consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual patient is recommended. (Level of Evidence: C)"

Class III: Harm
"1. AF catheter ablation should not be performed in patients who cannot be treated with anticoagulant therapy during and following the procedure. (Level of Evidence: C)"
"2. AF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation. (Level of Evidence: C)"

Class IIa
"1. AF catheter ablation is reasonable for selected patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication. (Level of Evidence: A)"
"2. In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm control strategy prior to therapeutic trials of antiarrhythmic drug therapy, after weighing risks and outcomes of drug and ablation therapy. (Level of Evidence: B)"

Class IIb
"1. AF catheter ablation may be considered for symptomatic long-standing (>12 months) persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication, when a rhythm control strategy is desired. (Level of Evidence: B)"
"2. AF catheter ablation may be considered prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication for symptomatic persistent AF, when a rhythm control strategy is desired. (Level of Evidence: C)"

Pharmacological Agents for Preventing AF and Maintaining Sinus Rhythm

Therapies to maintain sinus rhythm
Treatment	Efficacy	Adverse effects	Contraindications	Precausions
Drug therapy
Beta-blockers	Low Sinus rhythm is maintained in <20% of patients Symptoms are reduced in >=20% of patients	Fatigue Bradycardia Monitor for bradycardia	Bradycardia Hypotension	Monitor for bradycardia
Nondihydropyridine Calcium Channel Blockers: Verapamil Diltiazem	Low Sinus rhythm is maintained in <20% of patients Symptoms are reduced in >=20% of patients	Edema Bradycardia Hypotension	Bradycardia [[Hypotension Heart failure with reduced ejection fraction
Flecainide	Moderate AF is prevented or reduced in 50-70% of patients	Uncommon Proarrhythmia risk in patients with structural heart disease	Structural heart disease (proarrhythmia risk)	Evaluate for ischemic heart disease before initiation of therapy
Propafenone	Moderate AF is prevented or reduced in 50-70% of patients	Dysgeusia	Structural heart disease (proarrhythmia risk)	Evaluate for ischemic heart disease before initiation of therapy
Quinidine	Moderate AF is prevented or reduced in 50-70% of patients	Gastrointestinal side effects	QT prolongation	Monitor for QT prolongation, polymorphic ventricular tachycardia
Disopyramide	Moderate AF is prevented or reduced in 50-70% of patients	Antimuscarinic effects Urinary retention	QT prolongation Heart failure	Monitor for QT prolongation,
Dronendrone	Moderate AF is prevented or reduced in 50-70% of patients	Uncommon	Heart failure	Monitor for: Fluid retention Hepatitis
Dofetilide	Moderate AF is prevented or reduced in 50-70% of patients	QT prolongation	QT prolongation Advanced renal disease	Monitor for QT prolongation (should be initiated in hospital)
Sotalol	Moderate AF is prevented or reduced in 50-70% of patients	QT prolongation Fatigue Bradycardia Hypotension	QT prolongation Advanced renal disease Bradycardia	Monitor for QT prolongation
Amiodarone	High AF is prevented or reduced in 80% of patients	Bradycardia Thyroid diseases Hepatitis Interstitial lung disease (pulmonary fibrosis) Neurologic dysfunction Photosensitivity	Bradycardia Hyperthyroidism	Monitor for systemic toxicities involving the thyroid, liver, lungs, and nervous system Monitor for drug interactions
Interventional procedures
Catheter ablation	High 60-80% of patients with paroxysmal AF are free from AF at 1 year 50% of patients with persistent AF are free from AF at 1 year Reduced AF burden	Procedure-related complications Risks associated with sedation and anesthesia Transient arrhythmia (for 3 months) For patients with persistent AF, a second procedure s often needed	Risks associated with sedation and anesthesia Catheter ablation is contraindicated if: vascular access is not possible vascular access is associated with high risks anticoagulation is contraindicated	Monitor for procedure-related complications (within the first 4 weeks) such as: tamponade esophageal injury Pulmonary vein stenosis (within months) Conversion of AF to rapid atrial flutter
Surgery (Maze procedure)	High AF is prevented in 80% of patients	Risks associated with anesthesia and surgery	Surgical contraindications	Monitor for complications of surgery

Sources

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation^[5]

ACCF/AHA/HRS 2011 Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation^[6]

ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines^[7]

ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter^[8]

ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation^[9]

References

↑ Pathak RK, Middeldorp ME, Meredith M, Mehta AB, Mahajan R, Wong CX; et al. (2015). "Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort: A Long-Term Follow-Up Study (LEGACY)". J Am Coll Cardiol. 65 (20): 2159–69. doi:10.1016/j.jacc.2015.03.002. PMID 25792361.
↑ ^2.0 ^2.1 ^2.2 Craig T. January, MD, PhD, FACC; L. Samuel Wann, MD, MACC, FAHA; Joseph S. Alpert, MD, FACC, FAHA; Hugh Calkins, MD, FACC, FAHA, FHRS; Joaquin E. Cigarroa, MD, FACC; Joseph C. Cleveland, Jr., MD, FACC; Jamie B. Conti, MD, FACC, FHRS; Patrick T. Ellinor, MD, PhD, FAHA; Michael D. Ezekowitz, MB, ChB, FACC, FAHA; Michael E. Field, MD, FACC, FHRS; Katherine T. Murray, MD, FACC, FAHA, FHRS; Ralph L. Sacco, MD, FAHA; William G. Stevenson, MD, FACC, FAHA, FHRS; Patrick J. Tchou, MD, FACC; Cynthia M. Tracy, MD, FACC, FAHA; Clyde W. Yancy, MD, FACC, FAHA. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive SummaryA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):2246-2280
↑ Dingxin Qin, George Leef, Mian Bilal Alam, Rohit Rattan, Mohamad Bilal Munir, Divyang Patel, Furqan Khattak, Evan Adelstein, Sandeep K. Jain, Samir Saba. Mortality risk of long-term amiodarone therapy for atrial fibrillation patients without structural heart disease. Cardiology Journal 2015;22(6):622-629.
↑ Echt et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo: the cardiac arrhythmia suppression trial. NEJM 1991; 324(12): 781-788.
↑ ^5.0 ^5.1 January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline 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 Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.
↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897
↑ Abraham NS, Hlatky MA, Antman EM, Bhatt DL, Bjorkman DJ, Clark CB; et al. (2010). "ACCF/ACG/AHA 2010 Expert Consensus Document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents". Circulation. 122 (24): 2619–33. doi:10.1161/CIR.0b013e318202f701. PMID 21060077.
↑ Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117 (8):1101-20. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199
↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) 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. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781

Template:WikiDoc Sources CME Category::Cardiology

[pmid25792361-1] Pathak RK, Middeldorp ME, Meredith M, Mehta AB, Mahajan R, Wong CX; et al. (2015). "Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort: A Long-Term Follow-Up Study (LEGACY)". J Am Coll Cardiol. 65 (20): 2159–69. doi:10.1016/j.jacc.2015.03.002. PMID 25792361.

[:0-2] 2.0 ^2.1 ^2.2 Craig T. January, MD, PhD, FACC; L. Samuel Wann, MD, MACC, FAHA; Joseph S. Alpert, MD, FACC, FAHA; Hugh Calkins, MD, FACC, FAHA, FHRS; Joaquin E. Cigarroa, MD, FACC; Joseph C. Cleveland, Jr., MD, FACC; Jamie B. Conti, MD, FACC, FHRS; Patrick T. Ellinor, MD, PhD, FAHA; Michael D. Ezekowitz, MB, ChB, FACC, FAHA; Michael E. Field, MD, FACC, FHRS; Katherine T. Murray, MD, FACC, FAHA, FHRS; Ralph L. Sacco, MD, FAHA; William G. Stevenson, MD, FACC, FAHA, FHRS; Patrick J. Tchou, MD, FACC; Cynthia M. Tracy, MD, FACC, FAHA; Clyde W. Yancy, MD, FACC, FAHA. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive SummaryA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):2246-2280

[3] Dingxin Qin, George Leef, Mian Bilal Alam, Rohit Rattan, Mohamad Bilal Munir, Divyang Patel, Furqan Khattak, Evan Adelstein, Sandeep K. Jain, Samir Saba. Mortality risk of long-term amiodarone therapy for atrial fibrillation patients without structural heart disease. Cardiology Journal 2015;22(6):622-629.

[4] Echt et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo: the cardiac arrhythmia suppression trial. NEJM 1991; 324(12): 781-788.

[JanuaryWann2014-5] 5.0 ^5.1 January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline 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 Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.

[pmid21382897-6] Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897

[pmid21060077-7] Abraham NS, Hlatky MA, Antman EM, Bhatt DL, Bjorkman DJ, Clark CB; et al. (2010). "ACCF/ACG/AHA 2010 Expert Consensus Document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents". Circulation. 122 (24): 2619–33. doi:10.1161/CIR.0b013e318202f701. PMID 21060077.

[pmid18283199-8] Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117 (8):1101-20. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199

[pmid16908781-9] Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) 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. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781

[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

v t e Electrocardiography
Overview	History of the EKG • EKG interpretation basics • Normal sinus rhythm
EKG Complexes	P wave • QRS complex • ST Segment • T wave • T wave alternans • Tombstone T wave • U wave Osborn wave • H wave • K wave • Delta wave NSSTW changes
EKG Intervals	PR Interval • QRS Interval • ST Interval • QT Interval
Conduction System & Bradycardia	Cardiac pacemaker • SA node • AV node• Bundle of His • Purkinje fibers • Sinus bradycardia • First Degree AV Block • Second Degree AV Block • Complete or Third-Degree AV Block • Concealed conduction • AV Junctional Rhythms • LBBB • LAHB • LPHB • RBBB • Trifascicular block
Atrial Arrhythmias	Sinus tachycardia • Premature Atrial Contractions (PACs) • Ectopic Atrial Rhythm • Paroxysmal Atrial Tachycardia (PAT) • Paroxysmal Atrial Tachycardia (PAT) with Block • Multifocal Atrial Tachycardia (MAT) • Atrial Flutter • Atrial Fibrillation • Wandering atrial pacemaker
Ventricular Arrhythmias	Differential Diagnosis of Tachycardia with a Wide QRS Complex • Accelerated Idioventricular Rhythm • Ventricular Parasystole • Premature Ventricular Contractions (PVCs) • Ventricular tachycardia • Ventricular Fibrillation • Sudden cardiac death
EKG Abnormalities in Disease States	Hypertrophy & Dilatation • Right atrial enlargement • Left atrial enlargement • Biatrial enlargement • Left Ventricular Hypertrophy • Right Ventricular Hypertrophy • Biventricular Hypertrophy • Acute myocardial infarction • NSTEMI • STEMI • Tombstone ST elevation • Right ventricular myocardial infarction • Atrial infarction Pre-excitation Syndromes • Wolff-Parkinson-White Syndrome • Lown Ganong Levine Syndrome • Mahaim Type Preexcitation Cardiomyopathies • Arrhythmogenic Right Ventricular Dysplasia • Dilated Cardiomyopathy • Hypertrophic Cardiomyopathy Drug Effects on the EKG • Adenosine • β-blockers • Digitalis • Quinidine • Procainamide • Disopyramide • Lidocaine • Tocainide and Mexiletine • Phenytoin • Encainide, Flecainide and Propafenone • Amiodarone • Bretylium • Ca Channel Blockers • Phenothiazines • Tricyclic Antidepressants • Lithium Congenital Heart Disease • Dextrocardia • Atrial Septal Defect • Ventricular Septal Defect • Tetralogy of Fallot • Conjoined Twins or Siamese Twins • Congenital heart block Electrolyte Disturbances • Hyperkalemia • Hypokalemia • Hypercalcemia • Hypocalcemia • Nonspecific Changes Other Heart Diseases • Pericarditis • Myocarditis • Tamponade • Heart Transplantation • Sick Sinus Syndrome • Long QT Syndrome Inherited Disease • Brugada Syndrome Systemic Diseases • CNS Disease • Cardiac Tumors Heart Transplantation • EKG Changes in patient with Heart Transplantation Exogenous Effects • Hypothermia • Chest Trauma • Insect Bites • Electric Injuries
Technical Issues and Potential Errors in Interpretation	Artifacts • Lead Placement Errors • The EKG in a Patient with a Pacemaker • EKG in athletes


Atrial Fibrillation Microchapters
Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Atrial Fibrillation from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Special Groups Postoperative AF Acute Myocardial Infarction Wolff-Parkinson-White Preexcitation Syndrome Hypertrophic Cardiomyopathy Hyperthyroidism Pulmonary Diseases Pregnancy ACS and/or PCI or valve intervention Heart failure

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram EKG Examples A-Fib with LBBB

Chest X Ray

Echocardiography

Holter Monitoring and Exercise Stress Testing

Cardiac MRI

Treatment

Rate and Rhythm Control

Cardioversion Overview Electrical Cardioversion Pharmacological Cardioversion

Anticoagulation Overview Warfarin Converting from or to Warfarin Converting from or to Parenteral Anticoagulants Dabigatran

Maintenance of Sinus Rhythm

Surgery Catheter Ablation AV Nodal Ablation Surgical Ablation Cardiac Surgery
Specific Patient Groups

Primary Prevention
Secondary Prevention

Supportive Trial Data

Cost-Effectiveness of Therapy

Case Studies

Case #1

Atrial fibrillation maintenance of rate control and sinus rhythm On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Atrial fibrillation maintenance of rate control and sinus rhythm

CDC on Atrial fibrillation maintenance of rate control and sinus rhythm

Atrial fibrillation maintenance of rate control and sinus rhythm in the news

Blogs on Atrial fibrillation maintenance of rate control and sinus rhythm

Directions to Hospitals Treating Atrial fibrillation maintenance of rate control and sinus rhythm

Risk calculators and risk factors for Atrial fibrillation maintenance of rate control and sinus rhythm