Atrial Fibrillation

Atrial FibrillationCLINICAL SIGNS:

* irregular heartbeat more or less fast between 60 and 160 / min with variable amplitudes, permanent or paroxysmal.

* no functional signs.

* or asthenia and moderate dyspnea.

* or palpitations or oppressions unpleasant, paroxysmal.

* or inaugural lipolysis or even syncope type Adams-Stokes.

* look for signs of valvulopathy (especially mitral) on auscultation.

* complications :

Functional or organic angina in relation to the underlying cardiac disease.

– cerebral arterial embolism.

– cardiac decompensation, OAP, collapse.

– convulsions, confusional state in the elderly person.

ETIOLOGY:

* mitral stenosis .

* Hypertrophic, dilated or obstructive cardiomyopathy.

* arterial hypertension.

* ischemic cardiomyopathy.

* hyperthyroidism.

* acute alcoholic intoxication.

* chronic respiratory failure.

* hypokalemia, hypo-hypercalcemia.

* atrial disease, WPW.

iatrogenic: digitalis, theophylline.

* idiopathic (20%).

DIAGNOSTIC TESTS:

* scope.

* ECG :

– absence of P wave.

– waves f (400 to 600 / mn): anarchic tremulations of the baseline, clearly visible in V1.

– The QRS complexes are fine (except in case of pre-existing block or conduction aberration), not equidistant.

* Blood ionogram , CPK, ASAT, LDH, TSH .

* chest x-ray.

* in a second time:

– holter ECG and echocardiography: volume of the atrium, thrombus, search for valvulopathies.

TREATMENT:

* Medicated if recent fibrillation or if old but poorly tolerated or complicated:

– venous route, possibly oxygen therapy to the mask.

– correct any hypokalemia.

– Digoxine Nativelle : 1 to 2 IV ampoules slow per day then ½ to 1 ampoule per day if f> 80 / min except if WPW, hypokalemia, polymorphic ESV, myocardial excitability, digitalis.

 or Cordarone (reduced better than Digoxine Nativelle, to prefer if underlying angina):

 loading dose: 30 mg / kg per os (or 1 cp / 10 kg), half-dose the next day.

 or route IV: 2 ampoules (300 mg) in infusion of 30 minutes then 600-1200 mg / d with the electric syringe.

 after TSH assay.

 sometimes in relay of the digoxin if failure of this one after 3 hours.

– effective anticoagulation before the attempt of reduction:

 Heparin:

IV bolus of 50 IU / kg.

 then 400 to 600 IU / kg / day to the electric syringe

 or LMWH in curative doses.

– reduction by electric shock under general anesthesia if failure of the drug treatment, in a second time.

* if old fibrillation and well tolerated:

– Digoxin: ½ to 1 cp per day depending on age +/- betablocker.

– preventive anticoagulation (Sintrom, Préviscan, Apegmone) unless contraindicated (give then Aspegic 250).

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Editor-in-chief of the Medical Actu website; general practitioner graduated from the Faculty of Medicine of Algiers in 2005 currently practicing as a liberal.

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