A 66 year-old man comes to the emergency department complaining of a several-day history of an intermittent sensation of fluttering in the chest. He feels weak when the episodes occur but denies chest pain or shortness of breath. He has had hypertension for 20 years controlled well with enalapril and he takes albuterol for asthma. He denies any alcohol use.
3 Case- cont
VS Temperature 36.8C (98.3F) Blood pressure 140/80 pulse 140/min respirations 12/min
PE supple neck no jugular vein distension or thyromegaly.
CV irregularly irregular rhythm with no rubs or gallops.
Chest clear sounds
Extremities no edema
4 Differential Diagnosis
Multifocal atrial tachycardia
5 Diagnostic plan
Thyroid Function tests
Long term hypertension
Irregularly irregular rhythm
EKG atrial fibrillation waves inconsistent R-R intervals absence P waves.
ATRIAL FIBRILLATION 7 Management
Ventricular rate control
Prevention of embolic complication
8 Patient with diagnosis of atrial fibrillation Hemodynamically stable Yes No
Control ventricular rate Diltiazem Cardioversion
Calcium Channel blockers
Long standing HTN Ischemic heart dz CHF Hyperthyroidism PE Lung ca Alcohol Hypother mia Electrolytes imbalance Etc. . Spontaneous conversion to sinus rhythm Yes No Assess cause of atrial fibrillation Contraindication to cardioversion Cont 9 Cont Yes No Cardiversion Start Heparin IV Warfarin Aspirin Consider long-term anticoagulation gt48hs lt48hs
Immediate medical or electrical cardioversion
Later elective cardioversion after 3weeks of warfarin
Early TEE-guided cardioversion
Long standing HTN Ischemic heart dz CHF Hyperthyroidism PE Lung ca Alcohol Hypother mia Electrolytes imbalance Etc. . Yes Atrial fibrillation persist No Assess cause of atrial fibrillation 10 References
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