Atrial Fibrillation ECG Interpretation with Sample Strip

ECG Strip

Atrial Fibrillation Rhythm Strip Features

Rate: Very fast (> 350 bpm) for Atrial, but ventricular rate may be slow, normal or fast
Rhythm: Irregular
P Wave: Absent – erratic waves are present
PR Interval: Absent
QRS: Normal but may be widened if there are conduction delays
Not all fibrillatory waves are created equal. The “f” waves can be coarse (majority measure 3 mm or more) or can be fine (majority of waveforms measure less than 3 mm) to almost absent.
Atrial fibrillation is a common type of supraventricular tachycardia (SVT) arrhythmia, characterized by chaotic, quivering atria. These atrial fibrillations result in atrial contractions that are ineffective and out of coordination with the ventricles.
External Source: http://www.nhlbi.nih.gov/health/health-topics/topics/af/
National Institutes of Health

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Authors and Sources

Authors and Reviewers

• ECG heart rhythm modules: Thomas O’Brien.
• ECG monitor simulation developer: Steve Collmann
• 12 Lead Course: Dr. Michael Mazzini, MD.
• Spanish language ECG: Breena R. Taira, MD, MPH
• Medical review: Dr. Jonathan Keroes, MD
• Medical review: Dr. Pedro Azevedo, MD, Cardiology
• Last Update: 11/8/2021

Sources

• Electrocardiography for Healthcare Professionals, 5th Edition

  Kathryn Booth and Thomas O’Brien
  ISBN10: 1260064778, ISBN13: 9781260064773
  McGraw Hill, 2019
  

• Rapid Interpretation of EKG’s, Sixth Edition

  Dale Dublin
  Cover Publishing Company

• 12 Lead EKG for Nurses: Simple Steps to Interpret Rhythms, Arrhythmias, Blocks, Hypertrophy, Infarcts, & Cardiac Drugs

  Aaron Reed
  Create Space Independent Publishing

• Heart Sounds and Murmurs: A Practical Guide with Audio CD-ROM 3rd Edition

  Elsevier-Health Sciences Division
  Barbara A. Erickson, PhD, RN, CCRN

• The Virtual Cardiac Patient: A Multimedia Guide to Heart Sounds, Murmurs, EKG

  Jonathan Keroes, David Lieberman
  Publisher: Lippincott Williams & Wilkin)
  ISBN-10: 0781784425; ISBN-13: 978-0781784429

• Project Semilla, UCLA Emergency Medicine, EKG Training

  Breena R. Taira, MD, MPH

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Atrial Fibrillation • LITFL • ECG Library Diagnosis

Atrial fibrillation (AF) is the most common sustained arrhythmia. It is characterised by disorganised atrial electrical activity and contraction.

The incidence and prevalence of AF is increasing. Lifetime risk over the age of 40 years is ~25%. Complications of AF include haemodynamic instability, cardiomyopathy, cardiac failure, and embolic events such as stroke.

ECG Features of Atrial Fibrillation

• Irregularly irregular rhythm
• No P waves
• Absence of an isoelectric baseline
• Variable ventricular rate
• QRS complexes usually < 120ms, unless pre-existing bundle branch block, accessory pathway, or rate-related aberrant conduction
• Fibrillatory waves may be present and can be either fine (amplitude < 0.5mm) or coarse (amplitude > 0.5mm)
• Fibrillatory waves may mimic P waves leading to misdiagnosis

Atrial fibrillation: Irregularly irregular ventricular rate without visible P waves

Mechanism of Atrial Fibrillation

The mechanisms underlying AF are not fully understood, but it requires an initiating event (focal atrial activity / PACs) and substrate for maintenance (i. e. dilated left atrium). Proposed mechanisms include:

• Focal activation – in which AF originates from an area of focal activity. This activity may be triggered due to increased automaticity or from micro re-entry. Often located in the pulmonary veins.
• Multiple wavelet mechanism – in which multiple small wandering wavelets are formed. The fibrillation is maintained by re-entry circuits formed by some of the wavelets. This process is potentiated in the presence of a dilated LA — the larger surface area facilitates continuous waveform propagation.

Left: Focal activation originating from pulmonary vasculature
Right: Multiple small wavelets, maintained by re-entry circuits

Causes of Atrial Fibrillation

• Ischaemic heart disease
• Hypertension
• Valvular heart disease (esp. mitral stenosis / regurgitation)
• Acute infections
• Electrolyte disturbance (hypokalaemia, hypomagnesaemia)
• Thyrotoxicosis
• Drugs (e. g. sympathomimetics)
• Alcohol
• Pulmonary embolus
• Pericardial disease
• Acid-base disturbance
• Pre-excitation syndromes
• Cardiomyopathies: dilated, hypertrophic.
• Phaeochromocytoma

Other features:

• Ashman Phenomenon – aberrant ventricular conducted beats, usually of RBBB morphology, secondary to a long refractory period as determined by the preceding R-R interval
• The ventricular response and thus ventricular rate in AF is dependent on several factors including vagal tone, other pacemaker foci, AV node function, refractory period, and medications
• AF is most commonly associated with a ventricular rate ~ 110 – 160
• AF is often described as having ‘rapid ventricular response’ once the ventricular rate is > 100 bpm.
• ‘Slow’ AF is a term often used to describe AF with a ventricular rate < 60 bpm.
• Causes of ‘slow’ AF include hypothermia, digoxin toxicity, and medications.
• A connection between Sick Sinus Syndrome (SSS) or Sinus node dysfunction (SND) and atrial fibrillation (AF) has been recognized in the literature since the 1960s. There is some evidence to support AF inducing SND and some support for the notion that SND causes and promotes the development of AF. [Sinus Node Dysfunction in Atrial Fibrillation: Cause or Effect?, 2008]

Classification of Atrial Fibrillation

Classification is dependent on the presentation and duration of atrial fibrillation as below:

• First episode – initial detection of AF regardless of symptoms or duration
• Recurrent AF – More than 2 episodes of AF
• Paroxysmal AF – Self terminating episode < 7 days
• Persistent AF – Not self terminating, duration > 7 days
• Long-standing persistent AF – > 1 year
• Permanent (Accepted) AF – Duration > 1 yr in which rhythm control interventions are not pursued or are unsuccessful

Note paroxysmal AF of > 48 hr duration is unlikely to spontaneously revert to sinus rhythm and anticoagulation must be considered.

Management of Atrial Fibrillation

Management of atrial fibrillation is complex, and depends on the duration of atrial fibrillation, co-morbidities, underlying cause, symptoms, and age. Management can be considered in a step-wise manner:

• Diagnosis of atrial fibrillation
• Assessment of duration
• Assessment for anticoagulation
• Rate or rhythm control
• Treatment of underlying / associated diseases

Guidelines for the Management of Atrial Fibrillation

A number of national and international guidelines exist for the management of AF including:

• European Society of Cardiology Guidelines 2016
• American College of Cardiology Foundation Atrial Fibrillation Toolkit
• Canadian Cardiovascular Society Guidelines 2016
• NICE Guideline Atrial fibrillation management

Risk of Stroke and Anticoagulation

• Atrial fibrillation is associated with disorganised atrial contraction and stasis within the left atrial appendage with associated thrombus formation and risk of embolic stroke
• AF associated with valvular disease has a particularly high risk of stroke
• Guideline recommendations for stroke prevention and anticoagulation also include atrial flutter due to the high likelihood of these patients developing AF
• Anticoagulation strategies may include NOACs, warfarin, aspirin, and clopidogrel
• Anticoagulation guidelines are based on risk of stroke vs. risk of bleeding.
• Stroke risk stratification requires either an assessment of risk factors or application of a risk score e.g. CHADS₂ or CHA₂DS₂VASc.
• CHADS2 calculator via MDCalc
• CHA2DS2-VASc calculator via MDCalc

Atrial Fibrillation in Wolff-Parkinson-White Syndrome

• Atrial fibrillation can occur in up to 20% of patients with Wolff-Parkinson-White Syndrome (WPW)
• The accessory pathway allows for rapid conduction directly to the ventricles bypassing the AV node
• Rapid ventricular rates may result in degeneration to VT or VF

ECG features of Atrial Fibrillation in WPW:

• Rate > 200 bpm
• Irregular rhythm
• Wide QRS complexes due to abnormal ventricular depolarisation via accessory pathway
• QRS complexes change in shape and morphology
• Axis remains stable, unlikely polymorphic VT

Treatment

• Treatment with AV nodal blocking drugs e. g. adenosine, calcium-channel blockers, beta-blockers may increase conduction via the accessory pathway with a resultant increase in ventricular rate and possible degeneration into VT or VF
• In a haemodynamically unstable patient urgent synchronised DC cardioversion is required.
• Medical treatment options in a stable patient include procainamide or ibutilide, although DC cardioversion may be preferred

AF with WPW explained with EDexam

ECG Examples

Example 1

Atrial fibrillation:

• Irregular ventricular response
• Coarse fibrillatory waves are visible in V1
• “Sagging” ST segment depression is visible in V6, II, III and aVF, suggestive of digoxin effect

Example 2

Atrial fibrillation:

• Irregular ventricular response
• Coarse fibrillatory waves are visible in V1

Example 3

Atrial fibrillation:

• Irregular ventricular response
• No evidence of organised atrial activity
• Fine fibrillatory waves seen in V1

Example 4

AF with rapid ventricular response

• Irregular narrow-complex tachycardia at ~135 bpm
• Coarse fibrillatory waves in V1

Example 5

AF with slow ventricular response

• Irregular heart rate with no evidence of organised atrial activity
• Fine fibrillatory waves in V1
• ST depression / T wave inversion in the lateral leads could represent ischaemia or digoxin effect
• The slow ventricular rate suggests that the patient is being treated with an AV-nodal blocking drug (e. g. beta-blocker, verapamil/diltiazem, digoxin). Another cause of slow AF is hypothermia

Example 6

Ashman phenomenon:

There are two aberrantly conducted complexes — each follows a long RR / short RR cycle (= Ashman phenomenon).

More On This Topic

• Atrial flutter
• Ashman Phenomenon (1947) with Prof Richard Ashman

References

• Wiesbauer F. Atrial Fibrillation Management Essentials. Medmastery
• ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006 Aug 15;114(7):e257-354.
• Medi C, Hankey GJ, Freedman SB. Atrial fibrillation. Med J Aust. 2007 Feb 19;186(4):197-202
• Medi C, Hankey GJ, Freedman SB. Stroke risk and antithrombotic strategies in atrial fibrillation. Stroke. 2010 Nov;41(11):2705-13
• Kezerashvili A, Krumerman AK, Fisher JD. Sinus Node Dysfunction in Atrial Fibrillation: Cause or Effect? J Atr Fibrillation. 2008 Sep 16;1(3):30
• Stiell IG, Macle L; CCS Atrial Fibrillation Guidelines Committee. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: management of recent-onset atrial fibrillation and flutter in the emergency department. Can J Cardiol. 2011 Jan-Feb;27(1):38-46; 47-59
• Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace. 2010 Oct;12(10):1360-420
• 2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline) A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011, 123:104-123

Advanced Reading

Online

• Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics. Medmastery
• Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course: Become an ECG expert. Medmastery
• Kühn P, Houghton A. ECG Mastery: Black Belt Workshop. Advanced ECG interpretation. Medmastery
• Rawshani A. Clinical ECG Interpretation ECG Waves
• Smith SW. Dr Smith’s ECG blog.

Textbooks

• Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
• Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
• Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
• Hampton J. The ECG Made Practical 7e, 2019
• Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
• Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography 1e, 2009
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
• Mattu A, Brady W. ECG’s for the Emergency Physician Part I 1e, 2003 and Part II
• Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004
• Smith SW. The ECG in Acute MI. 2002 [PDF]

LITFL Further Reading

• ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
• ECG A to Z by diagnosis – ECG interpretation in clinical context
• ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
• 100 ECG Quiz – Self-assessment tool for examination practice
• ECG Reference SITES and BOOKS – the best of the rest

Ed Burns

Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

Robert Buttner

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

Diagnostics and treatment of atrial fibrillation (atrial fibrillation) in Krasnoyarsk

Atrial fibrillation (AF), or atrial fibrillation (many doctors still call it that), is one of the most common arrhythmias. It is more common in older people than in younger people. Let’s figure out together why it occurs – the causes of atrial fibrillation – and how it can be dangerous for a person.

In the human heart there are not only muscle cells (myocardium), which contract and ensure the work of the heart as a pump for pumping blood, but also special cells that generate electric current and conduct it to the myocardium. The so-called conduction system of the heart consists of these special cells, through which an electrical impulse propagates. In a healthy heart, an electrical impulse that stimulates the contraction of the heart occurs in the right atrium, in the sinus node. Therefore, a normal heart rhythm is called sinus. From the sinus node, the impulse propagates along the fibers of the conducting system in the atria, causing them to contract. Blood is pumped through the open mitral and tricuspid valves into the ventricles of the heart. Then the impulse enters the atrioventricular node (atrioventricular), which is a kind of checkpoint into the ventricles. Fibers come out of it, called the “legs of the bundle of His”. Moving along the bundle of His, the impulse leads to a contraction of the ventricles and the release of blood into the aorta and pulmonary artery.

In a healthy heart, the impulse is formed at regular intervals, from 60 to 90 times per minute. In different situations, the pulse rate of the same person is 60 (for example, in a state of rest and rest), and 90 (during physical exertion, excitement) beats per minute. By changing the pulse rate, a healthy heart adjusts to the body’s changing oxygen needs. The same happens with blood pressure, which can vary throughout the day from 100/70 to 140/90 mmHg Art. (fine).

What is atrial fibrillation?

When atrial fibrillation (atrial fibrillation) the electrical impulse moves through the atria chaotically, instead of “friendly” contraction of the atria, they tremble, “flicker”. Due to the fact that the muscle fibers of the atria contract at different times, there is no single contraction and ejection of blood into the ventricles. Since the atria begin to contract not only chaotically, but also very often, the atrioventricular node does not pass all the contractions to the ventricles, an equal period of time is not observed. Therefore, when you try to count the pulse, the intervals between beats will be different, and the pulse will be “uneven”. Also note that the pulse has become different in content – one contraction is stronger, and the other can barely be determined under the fingers. The reason for this phenomenon is the disorganized work of the heart. Part of the contractions of the ventricles occurs when they have had time to fill with blood, and part – with empty ventricles, “idling. ”

Forms

Atrial fibrillation (atrial fibrillation) may be paroxysmal or chronic. If attacks of arrhythmia (paroxysms) do not last long (from a few minutes to 7 days) and the normal rhythm is restored spontaneously, this form of atrial fibrillation is called paroxysmal.

Can atrial fibrillation be a health hazard?

Atrial fibrillation (atrial fibrillation) in most cases does not directly threaten your life, as it happens with ventricular tachycardia, ventricular fibrillation. To a greater extent, atrial fibrillation affects the accelerated development of heart failure, reducing the quality of human life. However, in certain situations, patients with atrial fibrillation are at risk. The chaotic contraction of the muscle fibers of the atria leads to the fact that instead of a complete simultaneous emptying of blood from the atria into the ventricles, the blood begins to stagnate in the atria. Conditions arise for the formation of blood clots (thrombi), which sometimes move with the blood flow into the ventricles and further into the systemic circulation. Such traveling clots (emboli) can clog the vessels of the brain (causing a stroke), limbs, and internal organs. Complication can be fatal.

The most favorable conditions for the formation of blood clots are created in chronic (permanent) form of atrial fibrillation , or if paroxysm atrial fibrillation lasts more than 2 days. In addition, AF (atrial fibrillation) contributes to the onset and progression of heart failure and coronary insufficiency. In patients with cardiac arrhythmia, the quality of life is significantly reduced: a constant feeling of danger of arrhythmia at any time, complete dependence on the availability of medical care.

Symptoms of atrial fibrillation (atrial fibrillation)

Atrial fibrillation, or atrial fibrillation , manifests itself in different ways: ic). With paroxysmal form of fibrillation , attacks of different duration occur, from several minutes to 7 days. Such attacks stop spontaneously. With a stable form of atrial fibrillation , paroxysms do not go away on their own, last more than 7 days, the help of doctors is needed to restore sinus rhythm (medication or electrical impulse therapy). At permanent form of atrial fibrillation fails to restore sinus rhythm.

Most often, atrial fibrillation begins with a paroxysmal form, later the attacks become more frequent, longer, it is more and more difficult to restore sinus rhythm, and then it is not possible at all – atrial fibrillation passes into a permanent form . For any form of atrial fibrillation, drug treatment is required, which should be carried out under the supervision of a physician. Atrial fibrillation can be detected during a screening mass ECG study, for example, when recording a stationary ECG during a physical examination or accidentally, when recording an ECG over the phone at a sports center, pharmacy or laboratory. Sometimes paroxysm of atrial fibrillation may develop during exercise tests, such as bicycle ergometry (VEM). But most often paroxysms of atrial fibrillation (atrial fibrillation) can be registered during long hours of ECG recording on a special small portable monitor – Holter monitoring .

Causes of atrial fibrillation (atrial fibrillation)

Causes that lead to atrial fibrillation (atrial fibrillation) may be different. Atrial fibrillation can be an independent disease (idiopathic form), but more often atrial fibrillation occurs in people suffering from cardiovascular diseases: valvular heart disease, coronary heart disease, hypertension, cardiomyopathy, pericarditis and myocarditis, heart surgery. Also at risk of getting atrial fibrillation are people suffering from thyroid pathology (hyperthyroidism – thyrotoxicosis, or “toxic goiter”). Sometimes rhythm disturbance is the first manifestation of thyroid disease, so at the first paroxysm of atrial fibrillation doctors always examine her.

The following video (in English) describes atrial fibrillation in great detail and clearly:

Alcohol abuse is also a common cause of atrial fibrillation . Frequent alcohol intake disrupts the level and balance of electrolytes in the blood (potassium, sodium and magnesium ions are very important for the work of any muscles, but primarily for the heart) and has a direct toxic effect on the heart, leading to the expansion of the atria and ventricles, reducing contractile function. Perhaps the appearance of atrial fibrillation in patients with chronic lung diseases, against the background of general severe diseases, pathology of the gastrointestinal tract (reflux esophagitis, hiatal hernia) is also one of the causes of atrial fibrillation, or atrial fibrillation.

Atrial fibrillation: what to do, how to treat?

Diagnosis of atrial fibrillation (atrial fibrillation) is based on an electrocardiogram (ECG) recording. Sometimes atrial fibrillation is asymptomatic and is detected by chance, for example, when an ECG is recorded with prof. examination or during inpatient treatment for another disease. However, most often the patient goes to the doctor with complaints of interruptions in the work of the heart, attacks of rapid, irregular heartbeat, which may be accompanied by weakness, shortness of breath, sweating, dizziness, a feeling of “internal trembling”, pain in the heart area and a decrease in blood pressure. When an attack occurs suddenly, you should definitely consult a doctor or call an ambulance team. It is very important that the ECG recording be made exactly at the time of the attack – the doctor will be able to accurately determine the nature of the arrhythmia, make a diagnosis and prescribe the correct treatment.

If attacks occur frequently enough, but they cannot be “caught” on a conventional ECG, the patient is referred for 24-hour ECG monitoring (Holter, Holter monitoring). Within 24 hours (or more, depending on the device), the patient’s ECG is recorded and recorded electronically with a special palm-sized device that the patient carries with him. The record is processed on a computer, and if during the examination the patient had attacks of arrhythmia, they will be recorded and documented. The doctor will receive all the necessary information.

It may happen that no seizure occurs during Holter monitoring. A second study will be required, and so on until the arrhythmia is “caught”. If seizures are rare, this is very difficult to do. In such cases, the doctor may recommend a test to provoke the onset of an attack – transesophageal atrial stimulation (TEAS). When performing PPSP, a thin electrode is inserted through the patient’s nose into the esophagus, which is installed at the level of the atria and, using a special device, allows electrical impulses to be applied to the heart. If a paroxysm of AF occurs, an ECG is recorded, then sinus rhythm is restored. CHPSP is carried out only in a hospital, in special departments specializing in the treatment of cardiac arrhythmias.

Atrial fibrillation paroxysm – what to do?

If you experienced an attack of uneven heart palpitations for the first time, you should immediately consult a doctor or call an ambulance team. Even if you feel good. Remember – it is very important to fix the attack on the ECG. The attack may end on its own after a while, but it is necessary to restore the correct rhythm within the first two days. The more time passes from the onset of the paroxysm, the more difficult it is for the heart to restore normal functioning and the higher the risk of blood clots in the chambers of the heart. If more than two days have passed since the onset of the attack or you do not know exactly the time of its occurrence, it is necessary to restore the heart rhythm only under the supervision of a doctor after examining the heart chambers on echocardiography, echocardiography (to exclude already formed blood clots) and special preparation with blood thinners (to prevent thrombosis).

If paroxysms of atrial fibrillation (atrial fibrillation) occur frequently, it is necessary to develop a plan of action with your doctor during an attack. With good tolerability of arrhythmia and with short (no more than 24 hours) attacks of arrhythmia, which often end on their own, you can not take special actions. It is necessary to continue taking the drugs recommended by the doctor without changing the dose. Your doctor may recommend a single dose of an antiarrhythmic drug in addition to basic therapy, or a temporary increase in the dose of medications already taken, when an attack occurs. If during the paroxysm of atrial fibrillation the state of health worsens significantly, or the arrhythmia lasts more than a day, a visit to the doctor is mandatory.

Which is “better” – seizures or persistent atrial fibrillation (atrial fibrillation)?

For a long time, doctors believed that the only optimal result of treatment was the restoration of proper, sinus rhythm. And now, in most cases, the doctor will advise you by all means to restore and maintain sinus rhythm. However, not in all cases. Studies have shown that if it is impossible to effectively maintain the restored sinus rhythm (when the heart constantly “breaks” into atrial fibrillation), permanent atrial fibrillation (atrial fibrillation) with medically controlled heart rate of about 60 beats per minute is safer than frequent paroxysms of atrial fibrillation (especially protracted, requiring the introduction of high doses of antiarrhythmic drugs or electrical impulse therapy).

The physician decides whether to restore sinus rhythm or maintain permanent atrial fibrillation. In each case, such a decision is individual and depends on the cause of the development of arrhythmia, the disease against which it arose, on its tolerance and the effectiveness of the treatment of atrial fibrillation to maintain the correct rhythm.

An attack that lasts more than two days should be treated only under medical supervision, after special training. If sinus rhythm is successfully restored, your doctor will adjust your ongoing antiarrhythmic therapy and recommend taking blood thinners for at least a month after cardioversion.

Treatment of atrial fibrillation (atrial fibrillation)

There are several ways to treat atrial fibrillation (atrial fibrillation) – restore sinus rhythm. This is the intake of antiarrhythmic drugs inside, the introduction of antiarrhythmic drugs intravenously and cardioversion (electropulse therapy, EIT). If the doctor restores the rhythm in the clinic or at the patient’s home, most often they start with intravenous drugs, then taking pills. The procedure is carried out under ECG control, the doctor observes the patient for 1-2 hours. If the restoration of sinus rhythm has not occurred, the patient is hospitalized in a hospital. In the hospital, drugs can also be administered intravenously, but if the time is limited (the duration of the attack approaches the end of the second day) or the patient does not tolerate the paroxysm (a decrease in blood pressure is observed, etc.), EIT is more often used.

Cardioversion is performed under intravenous anesthesia, so the electrical shock is painless for the patient. The success of rhythm recovery depends on many factors: the duration of the attack, the size of the heart cavities (in particular, the left atrium), sufficient saturation of the body with an antiarrhythmic drug), etc. EIT efficiency approaches 90-95%.

If the paroxysm of atrial fibrillation lasts more than two days, it is possible to restore the rhythm only after special training. The main stages are taking blood-thinning drugs under the control of a special analysis (INR) and transesophageal echocardiography (TEE) before EIT to exclude blood clots in the heart cavities.

Attacks of atrial fibrillation – how to prevent?

In order for the paroxysms of atrial fibrillation not to resume, the patient must constantly take an antiarrhythmic drug. For the purpose of prevention. To date, there are many antiarrhythmics, the choice of the drug should be made by the doctor. A patient with atrial fibrillation needs to be monitored by a cardiologist, during which regular examinations are carried out (for example, echocardiography once a year, or daily Holter monitoring, if necessary, to assess the effectiveness of treatment), treatment correction. The selection of drug therapy is always, for any disease, a very painstaking task that requires literacy and perseverance on the part of the doctor and understanding and diligence on the part of the patient. Individual can be not only the effectiveness, but also the tolerability of treatment.

Failure of medical therapy for atrial fibrillation may be an indication for surgical treatment. In the left atrium (near the confluence of the pulmonary veins) there are zones in which electrical impulses are formed that can trigger atrial fibrillation. The increased electrical activity of these zones can be detected using a special electrophysiological examination (EPS). A special catheter is inserted into the cavity of the heart, the information obtained allows you to make an electrical “map” and determine the trigger (“starting”) areas. The study is performed under local anesthesia and is quite safe for the patient. After determining the “starting” areas, an operation is performed – radiofrequency ablation of trigger zones (RFA). The catheter, using high-frequency current, destroys these areas and disrupts the triggering of the arrhythmia. In four cases out of five, atrial fibrillation no longer resumes. In an animated form, the RFA process of trigger zones in atrial fibrillation is presented in the video.

Atrial fibrillation became permanent

In a certain proportion of patients suffering from attacks of atrial fibrillation, sooner or later there comes a time when it is no longer possible to restore sinus rhythm. Atrial fibrillation becomes permanent. As a rule, this happens in patients with significantly enlarged left atrium (4.5 cm or more). Such an enlarged atrium is simply not able to maintain sinus rhythm. With a permanent form, the patient also needs medical supervision.

The goals of treatment are to keep the heart rate within 60-70 beats per minute at rest, prevent the formation of blood clots in the heart cavities and reduce the risk of thromboembolic complications.

Heart rate control is carried out with beta-blockers, digoxin or calcium antagonists (verapamil group), selecting an individual dose of the drug according to the principle “the higher the dose, the lower the heart rate.” At the optimal dose, the titration is completed and the patient receives it daily. The effectiveness of heart rate control can be assessed using 24-hour Holter ECG monitoring. If a decrease in the frequency of the rhythm cannot be achieved with pills, doctors resort to surgical methods. The arrhythmologist surgeon isolates the atria from the ventricles and implants a pacemaker that is programmed for a certain number of heartbeats at rest and adapts to stress.

To prevent thrombus formation, drugs are used that “thinn” the blood, that is, slow down the processes of blood clotting. For this purpose, aspirin and anticoagulants (most often warfarin) are used. To date, the approach to the tactics of anticoagulant therapy is determined on the basis of an assessment of the risk of thromboembolic complications and the risk of bleeding while taking these drugs, and is approved in the National Russian recommendations of the All-Russian State Audit Committee.

Many patients are afraid to start taking medications because complications such as bleeding are listed in the instructions. You should know that before prescribing anticoagulants, the doctor always weighs the benefits and risks of treatment with the drug, and prescribes only when he is completely sure that the benefits greatly outweigh the risks. Strict adherence to the recommendations and regular monitoring of blood tests (international normalized ratio (INR) for patients receiving warfarin) plus your awareness of the main mechanisms of action of the drug and the tactics of your actions at the first signs of bleeding make such treatment completely predictable and as safe as possible.

Relatively recently, endovascular occlusion of the left atrial appendage began to be performed in Russia to prevent the development of stroke in patients with chronic atrial fibrillation. The operation is an alternative to the use of anticoagulants in patients for whom these drugs are contraindicated, or for those who are indicated for the use of warfarin, but for one reason or another they do not receive it.