Paroxysmal atrial fibrillation: Difference between revisions
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Editors-In-Chief: [[C. Michael Gibson, M.S., M.D.]][mailto: | '''Editors-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]][mailto:charlesmichaelgibson@gmail.com] and [[Ann Slater]][mailto:aslater@perfuse.org], R.N., B.S.N. | ||
{{SI}} | {{SI}} | ||
'''''Related Key Words and Synonyms:''''' | |||
'''''Related Key Words and Synonyms:''''' PAF, paroxysmal AF | |||
== Overview == | == Overview == | ||
PAF is defined as recurrent episodes of atrial fibrillation that terminate spontaneously in less than 7 days. Oftentimes it terminates within 24 hours. | |||
== Epidemiology and Demographics == | == Epidemiology and Demographics == | ||
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{|style="width:80%; height:100px" border="1" | {|style="width:80%; height:100px" border="1" | ||
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular''' | |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular''' | ||
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | | |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Cardiomyopathy]], [[Congestive heart failure]] ([[CHF]]), following [[coronary artery bypass graft surgery]] ([[CABG]]), [[Coronary artery disease]], [[Hypertension]], [[Left ventricular hypertrophy]] ([[LVH]]), [[Mitral stenosis]], [[Mitral regurgitation]], [[Myocarditis]], [[Pericarditis]], [[Sick sinus syndrome]] ([[SSS]]), [[ST elevation MI]], | ||
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| '''Endocrine''' | | '''Endocrine''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| [[Hyperthyroidism]] | ||
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| '''Iatrogenic''' | | '''Iatrogenic''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| [[Cardiac catheterization]], [[coronary artery bypass grafting]] | ||
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| '''Nutritional / Metabolic''' | | '''Nutritional / Metabolic''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| Caffeine, [[alcohol]] withdrawal | ||
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|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
| '''Pulmonary''' | | '''Pulmonary''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| [[Pneumonia]], [[Pulmonary embolism]] | ||
|- | |- | ||
|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
| '''Renal / Electrolyte''' | | '''Renal / Electrolyte''' | ||
|bgcolor="Beige"| | |bgcolor="Beige"| [[Hypokalemia]] | ||
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|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
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|} | |} | ||
=== History and Symptoms === | === History and Symptoms === | ||
The most common symptom is [[palpitations]]. Often the patient describes an intermittent fluttering sensation in the chest. Less common symptoms include [[dizziness]] or [[lightheadedness]], [[syncope]], [[weakness]], [[shortness of breath]] and [[chest pain]]. The patient may be asymptomatic, and the diagnosis may only be picked up on a screening [[EKG]]. | |||
=== Physical Examination === | === Physical Examination === | ||
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====Vital Signs==== | ====Vital Signs==== | ||
The pulse may be irregularly irregular if the patient is sustaining an active episode of paroxysmal atrial fibrillation. | |||
====Skin==== | ====Skin==== | ||
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==== Electrolyte and Biomarker Studies ==== | ==== Electrolyte and Biomarker Studies ==== | ||
The patients [[thyroid function tests]] should be checked to exclude [[hyperthyroidism]]. [[Hypokalemia]] should be excluded. | |||
==== Electrocardiogram ==== | ==== Electrocardiogram ==== | ||
Often the patient is in [[normal sinus rhythm]]. When they are in paroxysmal atrial fibrillation, the following findings are present: | |||
#Absent [[P wave]]s | |||
#Irregularly irregular ventricular response rate. Regular [[RR]] intervals are possible in the presence of [[AV block]] or interference due to ventricular or junctional [[tachycardia]]. | |||
#An atrial rate that ranges from 400 to 700 BPM. | |||
#Sometimes lead V1 may look as though there is [[atrial flutter]]. This may be because the electrode overlies a portion of the [[RA]] with rhythmic activity. | |||
#Some authors believe that fine f waves (<.5 mm) are associated with coronary artery disease and that coarse F waves are associated with [[LA enlargement]] and [[rheumatic heart disease]]. | |||
#The ventricular rate is usually between 100 and 180 BPM. | |||
#If the atrial rate is greater than 200 BPM, then consider [[WPW]] or an [[accessory pathway]]. | |||
#In the presence of AV junctional disease, the ventricular rate may be below 70 bpm. | |||
#A rapid, irregular, sustained, wide-QRS-complex [[tachycardia]] strongly suggests AF with conduction over an [[accessory pathway]] or AF with underlying [[bundle-branch block]]. | |||
# [[Complete AV block]] is indicated by a slow ventricular rhythm with a regular RR interval. | |||
#In patients with electronic pacemakers, diagnosis of AF may require temporary inhibition of the pacemaker to expose atrial fibrillatory activity. | |||
#Differential diagnosis includes an [[EKG artifact]] such as a [[tremor]]. The oscillations in this case are largest in the limb leads. | |||
====Holter Monitoring==== | |||
Ambulatory event or [[Holter montoring]] is a cost effective tool that maybe considered. It provides a view of 2-3 leads over an extended time period, and sometimes is used as a diagnostic tool for the assessment of PAF. | |||
[http://stroke.ahajournals.org/cgi/content/full/35/7/e336 Holter Monitoring Is Useful Article] | |||
<ref name="urlHolter Monitoring Is Useful * Response -- Weir et al. 35 (7): e336 -- Stroke">{{cite web |url=http://stroke.ahajournals.org/cgi/content/full/35/7/e336 |title=Holter Monitoring Is Useful * Response -- Weir et al. 35 (7): e336 -- Stroke |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=2011-01-27}}</ref> | |||
==== Chest X Ray ==== | ==== Chest X Ray ==== | ||
While chronic atrial fibrillation is associated with an enlarged left atrial size, paroxysmal atrial fibrillation is generally not associated with an increase in left atrial size <ref name="pmid8712483">{{cite journal |author=Rostagno C, Olivo G, Comeglio M, Bertini G, Gensini GF, Galanti G |title=Left atrial size changes in patients with paroxysmal lone atrial fibrillation. An echocardiographic follow-up |journal=[[Angiology]] |volume=47 |issue=8 |pages=797–801 |year=1996 |month=August |pmid=8712483 |doi= |url=http://ang.sagepub.com/cgi/pmidlookup?view=long&pmid=8712483 |accessdate=2011-01-27}}</ref>. | |||
==== MRI and CT ==== | ==== MRI and CT ==== | ||
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== Acknowledgements == | == Acknowledgements == | ||
The content on this page was first contributed by: C. Michael Gibson, M.S., M.D. | The content on this page was first contributed by: [[C. Michael Gibson, M.S., M.D.]] | ||
==Contributors== | ==Contributors== | ||
[[Ann Slater]] | |||
{{WikiDoc Help Menu}} | {{WikiDoc Help Menu}} | ||
{{WikiDoc Sources}} | {{WikiDoc Sources}} | ||
[[Category: | [[Category:Disease]] | ||
Latest revision as of 19:44, 1 November 2012
Editors-In-Chief: C. Michael Gibson, M.S., M.D.[1] and Ann Slater[2], R.N., B.S.N.
Related Key Words and Synonyms: PAF, paroxysmal AF
Overview
PAF is defined as recurrent episodes of atrial fibrillation that terminate spontaneously in less than 7 days. Oftentimes it terminates within 24 hours.
Epidemiology and Demographics
Risk Factors
Screening
Pathophysiology & Etiology
Molecular Biology
Genetics
Natural History and Complications
Diagnosis
Common Causes
Complete Differential Diagnosis of the Causes of ...
(In alphabetical order)
- a...
- z...
Make sure that each diagnosis is linked to a page.
Complete Differential Diagnosis of the Causes of ...
(By organ system)
| Cardiovascular | Cardiomyopathy, Congestive heart failure (CHF), following coronary artery bypass graft surgery (CABG), Coronary artery disease, Hypertension, Left ventricular hypertrophy (LVH), Mitral stenosis, Mitral regurgitation, Myocarditis, Pericarditis, Sick sinus syndrome (SSS), ST elevation MI, |
| Chemical / poisoning | No underlying causes |
| Dermatologic | No underlying causes |
| Drug Side Effect | No underlying causes |
| Ear Nose Throat | No underlying causes |
| Endocrine | Hyperthyroidism |
| Environmental | No underlying causes |
| Gastroenterologic | No underlying causes |
| Genetic | No underlying causes |
| Hematologic | No underlying causes |
| Iatrogenic | Cardiac catheterization, coronary artery bypass grafting |
| Infectious Disease | No underlying causes |
| Musculoskeletal / Ortho | No underlying causes |
| Neurologic | No underlying causes |
| Nutritional / Metabolic | Caffeine, alcohol withdrawal |
| Obstetric/Gynecologic | No underlying causes |
| Oncologic | No underlying causes |
| Opthalmologic | No underlying causes |
| Overdose / Toxicity | No underlying causes |
| Psychiatric | No underlying causes |
| Pulmonary | Pneumonia, Pulmonary embolism |
| Renal / Electrolyte | Hypokalemia |
| Rheum / Immune / Allergy | No underlying causes |
| Sexual | No underlying causes |
| Trauma | No underlying causes |
| Urologic | No underlying causes |
| Miscellaneous | No underlying causes |
History and Symptoms
The most common symptom is palpitations. Often the patient describes an intermittent fluttering sensation in the chest. Less common symptoms include dizziness or lightheadedness, syncope, weakness, shortness of breath and chest pain. The patient may be asymptomatic, and the diagnosis may only be picked up on a screening EKG.
Physical Examination
Appearance of the Patient
Vital Signs
The pulse may be irregularly irregular if the patient is sustaining an active episode of paroxysmal atrial fibrillation.
Skin
Eyes
Ear Nose and Throat
Heart
Lungs
Abdomen
Extremities
Neurologic
Other
Laboratory Findings
Electrolyte and Biomarker Studies
The patients thyroid function tests should be checked to exclude hyperthyroidism. Hypokalemia should be excluded.
Electrocardiogram
Often the patient is in normal sinus rhythm. When they are in paroxysmal atrial fibrillation, the following findings are present:
- Absent P waves
- Irregularly irregular ventricular response rate. Regular RR intervals are possible in the presence of AV block or interference due to ventricular or junctional tachycardia.
- An atrial rate that ranges from 400 to 700 BPM.
- Sometimes lead V1 may look as though there is atrial flutter. This may be because the electrode overlies a portion of the RA with rhythmic activity.
- Some authors believe that fine f waves (<.5 mm) are associated with coronary artery disease and that coarse F waves are associated with LA enlargement and rheumatic heart disease.
- The ventricular rate is usually between 100 and 180 BPM.
- If the atrial rate is greater than 200 BPM, then consider WPW or an accessory pathway.
- In the presence of AV junctional disease, the ventricular rate may be below 70 bpm.
- A rapid, irregular, sustained, wide-QRS-complex tachycardia strongly suggests AF with conduction over an accessory pathway or AF with underlying bundle-branch block.
- Complete AV block is indicated by a slow ventricular rhythm with a regular RR interval.
- In patients with electronic pacemakers, diagnosis of AF may require temporary inhibition of the pacemaker to expose atrial fibrillatory activity.
- Differential diagnosis includes an EKG artifact such as a tremor. The oscillations in this case are largest in the limb leads.
Holter Monitoring
Ambulatory event or Holter montoring is a cost effective tool that maybe considered. It provides a view of 2-3 leads over an extended time period, and sometimes is used as a diagnostic tool for the assessment of PAF.
Holter Monitoring Is Useful Article [1]
Chest X Ray
While chronic atrial fibrillation is associated with an enlarged left atrial size, paroxysmal atrial fibrillation is generally not associated with an increase in left atrial size [2].
MRI and CT
Echocardiography or Ultrasound
Other Imaging Findings
Pathology
Gross Pathology
Microscopic Pathology
Other Diagnostic Studies
Risk Stratification and Prognosis
Treatment
Pharmacotherapy
Acute Pharmacotherapies
Chronic Pharmacotherapies
Surgery and Device Based Therapy
Indications for Surgery
Pre-Operative Assessment
Post-Operative Management
Transplantation
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
"The Way I Like To Do It ..." Tips and Tricks From Clinicians Around The World
Suggested Revisions to the Current Guidelines
References
- ↑ "Holter Monitoring Is Useful * Response -- Weir et al. 35 (7): e336 -- Stroke". Retrieved 2011-01-27.
- ↑ Rostagno C, Olivo G, Comeglio M, Bertini G, Gensini GF, Galanti G (1996). "Left atrial size changes in patients with paroxysmal lone atrial fibrillation. An echocardiographic follow-up". Angiology. 47 (8): 797–801. PMID 8712483. Retrieved 2011-01-27. Unknown parameter
|month=ignored (help)
External Links and Patient Resources
Acknowledgements
The content on this page was first contributed by: C. Michael Gibson, M.S., M.D.