RMH Field Care Audit: Atrial Fibrillation

1. Skipping Beats:
Atrial Fibrillation
Atrial Fibrillation
V. Bonales, M.D.
RMH - PCMD, HC EMMC PC

2. Problems of the
heart...

3. What is Normal?

4. Heart Tissues
n
Cardiac Myocytes
n
Specialized
n
Intrinsic Rhythm

5. Heart Anatomy

6. Intrinsic Rhythm
n
SA Node - 100 beats per minute (70 normal)
n
AV Node - 40 - 60 beats per minute
n
Purkinje Fibers - 30 - 40 beats per minute

7. Coronary Anatomy

8. The Heart Electric

9. EKG Regions

11. Normal Sinus

12. Rate
n
300
n
150
n
100
n
75
n
60

13. Heart Problems Rhythm
n
Regular
n
Irregular

14. Atrial Fibrillation

15. Atrial Fibrillation
n
A Fib

16. Atrial Fibrillation
n
Hemodynamic stress
n
Valve disease
n
Atrial ischemia
n
Inflammation
n
Respiratory causes
n
Alcohol and drug use
n
Endocrine disorders

17. Atrial Fibrillation
n
Patients present with:
n
Palpitations
n
Fatigue or poor exercise intolerance
n
Pre-syncope or syncope
n
Generalized weakness, dizziness, fatigue

18. Atrial Fibrillation
n
25% of individuals 40 and older will develop afib during their lifetime
n
Higher in men than in women
n
10 - 15% occurs with no other co-morbidities
n
Increases with age, women at higher risk

19. Holiday
Heart
- binge drinking
- usu. Symptom is
palpitations
- no prior Hx of heart
disease - recover w/in 24
hours
- some THC linkage

20. Atrial Fibrillation

22. Atrial Fibrillation

24. Atrial Fibrillation
Discrete P waves are absent, in the setting of irregular
QRS complexes
•Heart rate (typically in the 110-140 range, but rarely
over 160-170)
•Pre-excitation
•Left ventricular hypertrophy
•Bundle-branch block
•Acute or prior MI

25. Atrial Fibrillation

26. Atrial Fibrillation
n
Cardioconversion needed for:
n
Decompensated CHF
n
Hypotension
n
Uncontrolled angina/ischemia

27. Atrial Fibrillation
n
1.5 - 1.9 times increased risk of death
(thrombus)
n
Risk of ischemic stroke 5%/yr. (2-7x higher)
n
Worse for HTN/valve disease --> CHF
n
40% worse Px in AMI

28. Patient RW
n
Pleasant 88 yo brought here by son. Episode
today where he went to get up, he felt very
weak “wobbly.” He thought he was going to fall
down. He never really hit the ground and
injured himself. He had no chest pain or
palpitations. Due to his profound weakness, he
decided to come in for evaluation
n
PMHx: HTN, OA, glaucoma
n
PE: Irregularly irregular heartbeat

29. Patient RW

30. Patient RW
n
Diagnosed as new onset Atrial Fibrillation,
admitted to hospital,
n
d/c’d to home with coumadin, digoxin and coreg

31. Patient MC
n
86 yo brought in by paramedics tonight
because of SOB. Pt diagnosed with CHF a few
days ago. Patient woke up in the middle of the
night acutely SOB. Patient found to be in atrial
fibrillation with a ventricular rate of
approximately 145

32. Patient MC

33. Patient MC
n
PE:
n
n
n
HR 145 - 150 afib, 175/80, RR 24, O2 95%
on 2L
2+ pitting edema in LE bilaterally
CXR
n
Mild CHF

34. Patient MC
n
Given Cardizem, HR 100 - 120, given lasix
n
Admitted to hospital, transferred after 2 days
with recurrent RVR on multiple medications
n
Evaluated by cardiology and d/c’d on several
medication for rate control after being in CCU
on gtt.

35. Atrial Fibrillation
n
Mainstay of therapy
n
Rate control and anti-coagulation

36. Thank you...!