Atrial Fibrillation – The Most Spontaneous, Common and Unpredictable Arrhythmia

Change is a part of life, accepted, it is the only constant and some of us may even take comfort in the fact as it means nothing lasts forever. The best and sometimes the only source of hope in the toughest most trying times. This relieving sense of constant unpredictability to an A-Fib patient on the other hand is an urgent, uncontrollable reminder of how fleeting life is and they are constantly reminded of it by being thrown off their sense of stability with every heartbeat.

Atrial Fibrillation (A-Fib) is a heart condition that signals a serious health problem with a fast uncoordinated heartbeat which can sometimes feel like a quiver in the chest. The condition is caused due to a malfunction in the Sino Atrial Node (SA Node). The node is tasked with producing electric signals to maintain the synchronized beating of the heart’s chambers. It is the natural pacemaker and A-Fib is one of the many conditions caused by its inability to function normally.

The SA Node directs an electrical impulse initiating every heartbeat. It maintains a coordinated rhythm of contraction and expansion between the upper and lower chambers of the heart. In case of A-Fib, instead of the electrical signal originating in the SA Node, it appears randomly in a cluster of sporadic undirected electrical bursts in the heart chambers that lead to an irregular uncoordinated heartbeat. P wave in an ECG starts after the SA Node fires. An erratic baseline with an absent P wave in an ECG is an indication of a damaged Sino Atrial Node and is diagnosed as A-fib. The baseline is replaced by a flat oscillatory f wave.

Thanks to technology, its equally unpredictable and unstoppable rise in the healthcare industry has made it possible for providers to re-establish a sense of stability in a patient’s life. Remote monitoring apps, devices and tools have made it possible for continuous observation, timely intervention and swift care of patients with critical conditions. This level of comprehensive care helps alleviate stress levels that directly have a positive impact on patient’s quality of life helping them manage their condition with more confidence. Providers can benefit from the quality of care by reducing readmissions and saving time, costs and resources that can be further invested in high demand situations and cases that require hospitalisation.

Over 0.5% of the general population is affected by this condition making A-Fib the most common type of arrhythmia. Those over the age of 75 years are at a higher risk of A-Fib. It is also an immediate issue in most post-operative cases with 33% of the patients suffering from it after cardiac surgery within the first 4 days. These factors result in an increase in morbidity, hospital stay and readmissions.

It is diagnosed on the basis of duration, causes and frequency which are further categorised as acute-chronic and valvular-nonvalvular. When neglected one form of arrhythmia changes or progresses to another. This article will focus on the three main forms Paroxysmal, Persistent, and Permanent.

Paroxysmal

It is the most unpredictable kind of arrhythmia lasting anywhere between a few seconds to a few days and resolves itself spontaneously within 7 days without any treatment. 50% of A-Fib cases are paroxysmal and in some rare cases of high intensity of the episode, anticoagulation medications may be prescribed to reduce chances of stroke. Patients have advised a change in lifestyle as most cases are a result of sudden stressful activity and neglect in self-care. Overworking, addictions, heavy partying teamed with substance abuse can trigger an episode and is therefore prevalent in the young to middle-aged populations. Binge drinking is a popular cause for Paroxysmal A-Fib and is popularly termed as Holiday Heart Syndrome.

Persistent

This type of A-Fib lasts for at least 7 days and is treatable by medication or cardioversion. Anticoagulants, beta-blockers and calcium channel blockers are prescribed to control the condition or shocks are administered by electrical cardioversion to return the abnormal heart rhythm to normal by restoring the SA node function. Catheter ablation may also be performed in case of a substrate being the underlying cause. Older people, Smokers, pre-existing conditions such as high blood pressure, heart failure, coronary heart disease, chronic pulmonary obstructive disease (COPD), surgery and heart valve disorder increase your chances of developing this acute form of A-Fib.

Permanent

Treatments such as cardioversion, medication, and surgery do not help in the resumption of sinus rhythm in this stage of A-Fib. Medication may be prescribed to reduce the risk of clots and in hopes of controlling the patient’s heart rhythm but in most cases the heart is in a state of permanent A-Fib. The stress involved with the diagnosis of this type of A-Fib can cause further difficulty in the management of this condition as patients can feel the discomfort of this life-threatening condition constantly in fear of heart failure.
Some diseases that predispose a person to A-Fib are

  • Rheumatic Heart Disease
  • Hyperthyroidism
  • COAD
  • Sepsis Pericarditis
  • Pulmonary
  • Embolus
  •  ASD
  •  Hypokalemia
  • Hypomagnesemia
  • Hypertension
  • Ischemic Heart Disease
  • Valvular Heart Disease
  •  Congestive Cardiac Failure
  • Diabetes Mellitus

A-Fib can also be caused due to complications from diseased atrial muscle or other triggers such as

  • Increased atrial pressure
  • Increased atrial mass
  • Atrial Inflammation
  • Atrial Infiltration
  •  Atrial Fibrosis
  •  A Rapidly discharging atrial focus

A-Fib often has vague symptoms and 30% of the diagnoses are an incidental finding in patients who visit their physician with complaints of generalized weakness and fatigue. However, the most easily recognizable symptoms of A-fib apart from a flutter or a quiver felt in the chest are

  • Rapid and irregular heartbeat
  • Palpitations
  • Dizziness
  • Shortness of breath and anxiety
  • Confusion
  • Fatigue when exercising
  • Sweating
  • Chest pain or pressure
  • Fainting

A large percentage of people affected by A-Fib is under no serious threat as the condition corrects itself with the arrhythmia reverting to a normal sinus rhythm in 24-48hours. In the cases of persistent A-Fib treating any underlying conditions usually brings the heart back to health. Cardioversion has to be performed after 3 weeks of anticoagulation as a precaution to avoid clots from entering the circulatory system. Anticoagulation is a must for patients with Rheumatic Heart Disease and Prosthetic Valves.

Heart rate is kept under 100 during anticoagulation by Rate Control or Rhythm Control. According to a study by AFFIRM, Rate Control is considered a safer option as the side effects are fewer. Pharmaceutical drugs are administered to bring the heart rate to the required levels by affecting the ventricular movements. Whereas, Rhythm control is resorted to in case the former option is unsuccessful and can be risky and have side effects. In this procedure physicians attempt to directly restore the heartbeat by targeting the SA node through class 1 antiarrhythmic drugs or Radiofrequency Ablation for the younger populations.

In A-Fib patients are prepared for surgery by changing their blood-thinning medication with anticoagulation drugs. Specific steps must be taken in accordance with the stability of patient vitals to control heart rate and avoid tachycardia.

References

1. Miller’s Anesthesia 7th Edition

2. Kumar & Clark’s Clinical Medicine 8th Edition

3.  Cardiology An Illustrated Textbook by Newby & Grubb

4. Oxford Handbook of Ana

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