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| {| border="1" style="border-collapse:collapse" cellpadding="3" align="right" | | __NOTOC__ |
| | colspan="3" align="center" bgcolor="#ABCDEF" | Conduction | | |
| | {| class="infobox" style="float:right;" |
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| | |[[File:Siren.gif|30px|link=Atrial fibrillation resident survival guide]]||<br>||<br> |
| | |[[Atrial fibrillation resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | |} |
| | {| class="infobox" style="float:right;" |
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| | <small>Sinus rhythm</small> [[Image:Heart conduct sinus.gif|none|230px]] | | |[[Image:Heart conduct sinus.gif|150px|]]<BR><small>'''Sinus rhythm'''</small> |
| | <small>Atrial fibrillation</small> [[Image:Heart conduct atrialfib.gif|none|230px]]
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| |} | | |} |
| {{Infobox_Disease | | | {| class="infobox" style="float:right;" |
| Name = Atrial fibrillation |
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| Image = SinusRhythmLabels.png |
| | |[[Image:Heart conduct atrialfib.gif|150px]]<BR><small>'''Atrial fibrillation'''</small> |
| Caption = The P waves, which represent depolarization of the atria, are irregular or absent during atrial fibrillation. |
| | |} |
| DiseasesDB = 1065 |
| | {{Atrial fibrillation}} |
| ICD10 = {{ICD10|I|48||i|30}} |
| | {{Patient}} |
| ICD9 = {{ICD9|427.31}} |
| | {{CMG}} {{AE}} {{Anahita}} {{Laith}} {{SemRikken}} |
| ICDO = |
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| OMIM = |
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| MedlinePlus = 000184 |
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| eMedicineSubj = med |
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| eMedicineTopic = 184 |
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| eMedicine_mult = {{eMedicine2|emerg|46}} |
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| }} | |
| {{SI}} | |
| {{WikiDoc Cardiology Network Infobox}} | |
| {{CMG}} | |
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| '''Associate Editor-In-Chief:''' {{CZ}}
| | {{SK}} AF; afib; lone fibrillator |
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| {{Editor Join}}
| | ==[[Atrial fibrillation overview|Overview]]== |
| | ==[[Atrial fibrillation historical perspective|Historical Perspective]]== |
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| '''Synonyms and related keywords''': AF, Afib, fib
| | ==[[Atrial fibrillation classification|Classification]]== |
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| ==Overview==
| | ==[[Atrial fibrillation pathophysiology|Pathophysiology]]== |
| ===[[Atrial fibrillation overview|Overview]]===
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| ===[[Atrial fibrillation epidemiology|Epidemiology]]===
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| ==Diagnosis==
| | ==[[Atrial fibrillation causes|Causes]]== |
| ===[[Atrial fibrillation diagnosis overview|Overview]]===
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| ===[[Atrial fibrillation classification|Classification]]===
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| ===[[Atrial fibrillation etiology and differential diagnosis|Etiology and Differential Diagnosis]]===
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| ==Treatment==
| | ==[[Atrial fibrillation differential diagnosis|Differentiating Atrial Fibrillation from other Diseases]]== |
| ===[[Atrial fibrillation pharmacological treatment|Pharmacological Treatment]]===
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| ===[[Atrial fibrillation invasive treatment|Invasive Treatment]]===
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| ===[[Atrial fibrillation surgical treatment|Surgical Treatment]]===
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| ==Invasive treatment of atrial fibrillation== | | ==[[Atrial fibrillation epidemiology and demographics|Epidemiology and Demographics]]== |
| ====Radiofrequency ablation====
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| In patients with AF where rate control drugs are ineffective and it is not possible to restore sinus rhythm using cardioversion, non-pharmacological alternatives are available. For example, to control rate it is possible to destroy the bundle of cells connecting the upper and lower chambers of the heart - the [[atrioventricular node]] - which regulates heart rate, and to implant a [[artificial pacemaker|pacemaker]] instead. A more complex technique, which avoids the need for a pacemaker, involves ablating groups of cells near the pulmonary veins where atrial fibrillation is thought to originate, or creating more extensive lesions in an attempt to prevent atrial fibrillation from establishing itself.<ref name="pmid16908781"/>
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| [[Ablation]] is a newer technique and has shown some promise for cases of recurrent AF that are unresponsive to conventional treatments. [[Radiofrequency ablation]] (RFA) uses radiofrequency energy to destroy abnormal electrical pathways in heart tissue. The energy emitting probe ([[electrode]]) is placed into the heart through a [[catheter]] inserted into veins in the groin or neck. Electrodes that can detect electrical activity from inside the heart are also inserted, and the electrophysiologist uses these to "map" an area of the heart in order to locate the abnormal electrical activity before eliminating the responsible tissue. | | ==[[Atrial fibrillation risk factors|Risk Factors]]== |
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| Most AF ablations consist of isolating the electrical pathways from the [[pulmonary vein]]s (PV)<ref>[http://www.clevelandclinic.org/heartcenter/pub/atrial_fibrillation/pulmonaryvein_ablation.htm The Cleveland Clinic]</ref>, which are located on the posterior wall of the left atrium. All other veins from the body (including neck and groin) lead to the right atrium, so in order to get to the left atrium the catheters must get across the atrial septum. This is done by piercing a small hole in the septal wall. This is called a transseptal approach. Once in the left atrium, the physician may perform ''Wide Area Circumferential Ablation'' (WACA) to electrically isolate the PVs from the left atrium.<ref>[http://www.medscape.com/viewarticle/532503_2 Medscape] </ref>
| | ==[[Atrial fibrillation screening|Screening]]== |
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| Some more recent approaches to ablating AF is to target sites that are particularly disorganized in both atria as well as in the [[coronary sinus]] (CS). These sites are termed ''complex fractionated atrial electrogram'' (CFAE) sites.<ref>{{cite journal | author= Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T, Khunnawat C, Ngarmukos T. | title=A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate | journal=J Am Coll Cardiol | year=2004 | pages=2044–53 | volume=43 | issue=11 | pmid= 15172410 | doi= 10.1016/j.jacc.2003.12.054}}</ref>. It is believed by some that the CFAE sites are the cause of AF, or a combination of the PVs and CFAE sites are to blame. New techniques include the use of [[cryoablation]] (tissue freezing using a coolant which flows through the catheter), microwave ablation, where tissue is ablated by the microwave energy "cooking" the adjacent tissue, and high intensity focused ultrasound (HIFU), which destroys tissue by heating. This is an area of active research, especially with respect to the RF ablation technique and emphasis on isolating the pulmonary veins that enter into the left atrium.
| | ==[[Atrial fibrillation natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| Efficacy and risks of catheter ablation of atrial fibrillation are areas of active debate. A worldwide survey of the outcomes of 8745 ablation procedures<ref>{{cite journal | author=Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. | title=Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation | journal=Circulation | year=2005 | volume=111 | pages=1100–1105| pmid=15723973 | doi=10.1161/01.CIR.0000157153.30978.67}}</ref> demonstrated a 52% success rate (ranging from 14.5% to 76.5% among centers), with an additional 23.9% of patients becoming asymptomatic with addition of an antiarrhythmic medication. In 27.3% of patients, more than one procedure was required to attain these results. There was at least one major complication in 6% of patients. A thorough discussion of results of catheter ablation was published in 2007<ref>{{cite journal | author=Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ. | title=HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation | journal=Heart Rhythm | year=2007 | volume=4 | issue=6 | pages= 816–61 | pmid=17556213}}</ref>; it notes that results are widely variable, due in part to differences in technique, follow-up, definitions of success, use of antiarrhythmic therapy, and in experience and technical proficiency.
| | ==Special Groups== |
| | [[Postoperative atrial fibrillation|Postoperative AF]] | [[Atrial fibrillation acute myocardial infarction|Acute Myocardial Infarction]] | [[Atrial fibrillation Wolff-Parkinson-White preexcitation syndromes|Wolff-Parkinson-White Preexcitation Syndromes]] | [[Atrial fibrillation hypertrophic cardiomyopathy|Hypertrophic Cardiomyopathy]] | [[Atrial fibrillation hyperthyroidism|Hyperthyroidism]] | [[Atrial fibrillation pulmonary diseases|Pulmonary Diseases]] | [[Atrial fibrillation pregnancy|Pregnancy]] | [[Atrial fibrillation medical therapy in patients presenting with ACS and/or PCI or valve intervention|Patients Presenting with ACS and/or PCI or Valve Intervention]] |
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| ==Surgical treatment of atrial fibrillation== | | ==Diagnosis== |
| | | [[Atrial fibrillation history and symptoms|History and Symptoms]] | [[Atrial fibrillation physical examination|Physical Examination]] | [[Atrial fibrillation laboratory findings|Laboratory Findings]] | [[Atrial fibrillation electrocardiogram|Electrocardiogram]] | [[Atrial fibrillation EKG examples|EKG Examples]] | [[Atrial fibrillation with LBBB EKG examples|Afib with LBBB EKG Examples]] | [[Atrial fibrillation chest x ray|Chest X Ray]] | [[Atrial fibrillation echocardiography or ultrasound|Echocardiography]] | [[Atrial fibrillation other imaging findings|Holter Monitoring and Exercise Stress Testing]] | [[Atrial fibrillation cardiac MRI|Cardiac MRI]] |
| ===Maze procedure===
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| {{main|Maze procedure}}
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| James Cox, MD, and associates developed the Cox maze procedure, an open-heart surgical procedure intended to eliminate atrial fibrillation, and performed the first one in 1987. "Maze" refers to the series of incisions made in the atria, which are arranged in a maze-like pattern. The intention was to eliminate AF by using incisional scars to block abnormal electrical circuits (atrial macro reentry) that AF requires. This procedure required an extensive series of endocardial (from the inside of the heart) incisions through both atria, a median sternotomy (vertical incision through the breastbone) and cardiopulmonary bypass (heart-lung machine). A series of improvements were made, culminating in 1992 in the Cox maze III procedure, which is now considered to be the "gold standard" for effective surgical cure of AF. The Cox maze III is sometimes referred to as the "traditional maze", the "cut and sew maze", or simply the "maze".<ref>{{cite journal |author=Cox JL, Schuessler RB, Lappas DG, Boineau JP |title=An 8 1/2-year clinical experience with surgery for atrial fibrillation |journal=Ann. Surg. |volume=224 |issue=3 |pages=267-73; discussion 273-5 |year=1996 |pmid=8813255 |doi=}}</ref>
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| Minimaze surgery is minimally invasive cardiac surgery similarly intended to cure atrial fibrillation. The "Minimaze" procedure refers to "mini" versions of the original maze procedure. These procedures are less invasive than the Cox maze procedure and do not require a median sternotomy (vertical incision in the breastbone) or [[cardiopulmonary bypass]] (heart-lung machine). These procedures use microwave, radiofrequency, or acoustic energy to ablate atrial tissue near the pulmonary veins.
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| == Prognosis ==
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| ==Follow up & Secondary prevention==
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| ===Risk factors for ischemic stroke or systemic embolization in patient with non valvular [[atrial fibrillation]]===
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| Numbers represents relative risks<ref>Estes NAM 3rd, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS, McNamara RL, Messer JV, Ritchie JL, Romeo SJW, Waldo AL, Wyse DG. ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with non valvular 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 Performance Measures for Atrial Fibrillation). Circulation 2008; 117:1101–1120</ref>
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| #Advanced age (continuous, per decade) 1.4
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| #History of [[hypertension]] 1.6
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| #[[Heart failure]] or impaired left ventricular systolic function 1.4
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| #[[Coronary artery disease]] (CAD) 1.5
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| #[[Diabetes mellitus]] (DM) 1.7
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| #Previous [[stroke]] or [[Transient Ischemic Attack]] (TIA) 2.5
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| ==Clinical Trial Data==
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| Results from the Pulmonary Vein Antrum Isolation versus AV Node Ablation with Bi-Ventricular Pacing for Treatment of Atrial Fibrillation in Patients with Congestive Heart Failure (PABA-CHF) study suggest that pulmonary-vein (PV) isolation leads to better morphologic and functional results than atrioventricular (AV) node ablation with biventricular pacing for congestive heart failure (CHF) in patients with atrial fibrillation.
| | ==[[Atrial fibrillation overview of treatment|Treatment]]== |
| | ===[[Atrial fibrillation rate control|Rate and Rhythm Control]]=== |
| | [[Atrial fibrillation rate control|Rate Control]] | [[Atrial fibrillation maintenance of rate control and sinus rhythm|Maintenance of Sinus Rhythm]] |
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| In this prospective, multicenter study, 41 patients were randomized to PV isolation and 40 to AV node ablation with biventricular pacing. At 6 months, patients in the PV isolation group had higher mean ejection fractions (35% vs 29%, p<0.001), greater 6 minute distances walked (340 vs 297 meters, p <0.001), and better quality of life scores as determined by the Minnesota Living with Heart Failure questionnaire (60 vs 82, p<0.001, where lower scores indicate better quality of life) than those in the AV node ablation arm.
| | ===Cardioversion=== |
| | [[Atrial fibrillation cardioversion|Overview]] | [[Atrial fibrillation electrical cardioversion|Electrical Cardioversion]] | [[Atrial fibrillation pharmacological cardioversion|Pharmacological Cardioversion]] |
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| These PABA-CHF study findings thus suggest the potential advantages of performing PV isolation over AV node ablation with biventricular pacing for this patient population.
| | ===Anticoagulation=== |
| | [[Atrial fibrillation anticoagulation|Overview]] | [[Warfarin]] | [[Dabigatran#Converting from or to Warfarin|Converting from or to Warfarin]] | [[Dabigatran#Converting from or to Parenteral Anticoagulants|Converting from or to Parenteral Anticoagulants]] | [[Dabigatran]] |
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| Noted limitations of the study include using sites with extensive experience in performing ablations, an unblinded study design, and a relatively short follow-up time. (NEJM by Mohammed N. Khan, et al.)
| | ===Dabigatran=== |
| | [[dabigatran#Dosing|Dosing]] | [[Dabigatran#Surgery and Interventions|Discontinuation for Surgery and Interventions]] | [[Dabigatran#WARNINGS AND PRECAUTIONS| Warnings and Precautions]] | [[Dabigatran#Adverse Reactions|Adverse Reactions]] | [[Dabigatran#Use in Specific Populations|Use in Specific Populations Such as Pregnancy]] | [[Dabigatran#Overdosage|Overdosage]] | [[Clinical Pharmacology of Dabigatran|Clinical Pharmacology]] | [[FDA Review of Data From the RE-LY Trial on September 20th, 2010|FDA Review of the RE-LY Data]] | [[A comparison of the RE-LY and Rocket AF Trials ]] | [[Estimates of Cost Per Year of Life Saved for Dabigatran]] |
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| ==[[The Living Guidelines: Diagnosis and Management of Atrial Fibrillation|Guidelines: Diagnosis and Management of Atrial Fibrillation]]== | | ===Ablation=== |
| | [[Atrial fibrillation catheter ablation|Catheter Ablation]] | [[AV nodal ablation|AV Nodal Ablation]] | [[Atrial fibrillation surgical ablation|Surgical Ablation]] |
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| ==External links== | | ===Surgery=== |
| | [[Atrial fibrillation surgical treatment|Maze Open Heart Surgery]] |
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| * [http://www.americanheart.org/presenter.jhtml?identifier=4451 American Heart Association's page on atrial fibrillation]
| | ===[[Atrial fibrillation secondary prevention|Secondary Prevention]]=== |
| * [http://www.patient.co.uk/showdoc/23068682/ Atrial fibrillation]
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| * [http://www.jr2.ox.ac.uk/bandolier/booth/booths/AF.html Bandolier: Evidence-based medicine resource on atrial fibrillation]
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| * [http://my.clevelandclinic.org/heart/webchat/atrialfibrillation011608.aspx Cleveland Clinic Webchat - Atrial Fibrillation Webchat with Dr. Jennifer Cummings]
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| ==See also== | | ===[[Atrial fibrillation supportive trial data|Supportive Trial Data]]=== |
| * [[Atrial flutter]]
| | ===[[Atrial fibrillation cost-effectiveness of therapy|Cost-effectiveness of Therapy]]=== |
| * [[Ashman phenomenon]]
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| ==[[EKG Examples of atrial fibrillation]]== | | ==Case Studies== |
| | [[Atrial fibrillation case study one|Case #1]] |
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| ==External EKG Sources== | | ==Related Chapters== |
| *[http://www.emedu.org/ecg_lib/index.htm John Vozenilek's (MD) ECG Collection]
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| *[http://www.ecgpedia.org ECGpedia]
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| ==References==
| | *[[Atrial flutter]] |
| {{reflist|2}}
| | *[[Ashman phenomenon]] |
| | | *[[The Living Guidelines: Diagnosis and Management of Atrial Fibrillation | The AF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]] |
| ==Further Readings==
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| {{refbegin|2}}
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| * Fuster V, Rydén LE, Cannom DS, 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. | |
| * Estes NAM 3rd, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS, McNamara RL, Messer JV, Ritchie JL, Romeo SJW, Waldo AL, Wyse DG. ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with non valvular 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 Performance Measures for Atrial Fibrillation). Circulation 2008; 117:1101–1120
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| * Braunwald's Heart Disease, Libby P, 8th ed., 2007, ISBN 978-1-41-604105-4
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| * Hurst's the Heart, Fuster V, 12th ed. 2008, ISBN 978-0-07-149928-6
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| * Willerson JT, Cardiovascular Medicine, 3rd ed., 2007, ISBN 978-1-84628-188-4
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| {{refend}}
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| {{Electrocardiography}} | | {{Electrocardiography}} |
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