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ATRIAL FIBRILLATION

LEARNING OBJECTIVES
After completing this case study, the reader should be
able to:
Determine therapeutic goals for attaining ventricular rate control
or normal sinus rhythm in patients with heart disease presenting with
recurrent paroxysmal atrial fibrillation.
Describe the difference between recurrent paroxysmal and
persistent atrial fibrillation.
Understand the influence of obstructive sleep apnea on the recurrence
and risk of incident atrial fibrillation.
Recognize the importance of identifying and alleviating sleep disordered
breathing in patients with atrial fibrillation, hypertension and obstructive
sleep apnea.

PATIENT PRESENTATION
Chief Complaint

I feel tired and dizzy during the day, and my
heart feels like it is pumping too fast.

HPI
Mark Finley is a 53-year-old man who presents to the Emergent
Care Clinic with heart palpitations and dizziness. He has a 2-year
history of recurrent paroxysmal atrial fibrillation. He now has
morning headaches and feels tired throughout the day despite
sleeping 78 hours each night. At his last visit 6 months ago he
was in normal sinus rhythm. He has gained 6 kg since his last
visit. The severity of his dizziness fluctuates; the dizziness is
worst in the morning and during exercise. He has been seen
by his primary care provider in the Internal Medicine Clinic for
many years for HTN and recurrent paroxysmal atrial
fibrillation.

PMH
HTN (previously well controlled on current antihypertensive
regimen)
Recurrent paroxysmal atrial fibrillation (rate controlled)

FH
Both parents had HTN; father had obstructive sleep apnea
and died
of an early morning stroke at age 52, mother died in MVA at
age 63.
He has one brother who has hypertension.

SH
Mr. Finley manages a local grocery store and lives at home
with his
wife. He smoked 1 ppd for 10 years and quit 2 years ago. He
drinks
12 glasses of wine each week.

Meds
Lisinopril 20 mg po daily
Metoprolol 50 mg po twice daily
Amlodipine 10 mg po daily
Hydrochlorothiazide 25 mg po daily
Warfarin 5 mg po daily

All
NKDA

ROS
Headache but no blurred vision, chest pain, or fainting
spells;
complains of being tired during the day; mild SOB; 2+
pitting edema


Physical Examination

Gen
Cooperative overweight man in moderate distress

VS
BP 149/84 (supine), P 118 (irregular), RR 20, T 36.3C; Wt 108.3 kg, Ht 5'11''

Skin
Cool to touch, normal turgor and color

HEENT
PERRLA, EOMI; funduscopic exam reveals mild arteriolar narrowing but no
hemorrhages, exudates, or papilledema

Neck
Large and supple, no carotid bruits; no lymphadenopathy or thyromegaly, ()
JVD

Lungs/Thorax
Inspiratory and expiratory wheezes and rales bilaterally no rhonchi




CV
Tachycardia with irregular rate; normal S1, S2; (+) S3;
no S4

Abd
NT/ND, (+) BS; no organomegaly, () HJR

Genit/Rect
Stool heme ()

MS/Ext
Pulses 1+ weak, full ROM, no clubbing or cyanosis

Neuro
A & O 3; CN IIXII intact; DTR 2+, negative Babinski
ECG
Atrial fibrillation, ventricular rate 97 bpm, mild LVH

Echo
Evidence of diastolic dysfunction (LVEF 59%, LVEDP 15 mm Hg)
and moderate left atrial enlargement (5.3 cm). No thrombus seen.

Chest X-Ray
Bilateral basilar infiltrates

Assessment
Recurrent paroxysmal atrial fibrillation: moderately symptomatic.
Diastolic heart failure: preserved ejection fraction with increased
LVEDP, pulmonary and peripheral edema; start furosemide.
Possible sleep apnea: schedule sleep study during hospitalization.
HTN: maintain meds for blood pressure control.
DRUG LIST DOSAGE INDICATIONS TOXICITY CONTINUE?
OR NOT?
REPLACE?
OR NOT?
LISINOPRIL 20 mg po
daily
ACE Inhibitor
Contraindication:
Aortic valve
stenosis or cardiac
outflow
obstruction
.
discontinue
METOPROLOL-
for cardiac
arryand htn
50 mg po
twice daily
Beta-blocker Discontinue No
AMLODIPINE 10 mg po
daily
Calcium-
channel
blocker
HYDROCHLORO-
THIAZIDE

25 mg po
daily
Diuretic
WARFARIN 5 mg po
daily
Anti-
coagulant
Continue
Atrial Fibrillation: Cause, Diagnosis & Treatment
Atrial fibrillation (AF), also called a-fib, is the most common cardiac arrhythmia. The hallmarks of AF
are irregular and rapid atrial activity, with an irregular ventricular response that results in
compromised cardiac hemodynamics. AF is associated with serious morbidity and increased
mortality risk, even in cases when symptoms are slight. AF is a risk for congestive heart failure
(CHF), angina, cardiac remodeling, and embolic stroke. This course describes the pathophysiology
and epidemiology of AF.

Medications for atrial fibrillation (AF or AFib)
Medications are often prescribed to prevent and treat blood clots which can lead to a
stroke. Additional drugs may be prescribed to control heart rate and rhythm in the AFib
patient. These medications may also be used in conjunction with other treatments. The heart
rhythm can be more difficult to control. The longer you have untreated AFib, the less likely it is that
normal rhythm can be reestablished.
Preventing Clots with Medication (antiplatelets and anticoagulants)
Drugs such as blood thinners are given to patients to prevent blood clot formation or to treat an
existing blood clot. Examples include:
Aspirin
Warfarin
Other FDA approved anticoagulants such as dabigitran, rivaroxaban, and apixaban

ATRIAL FIBRILLATION
Not Sleeping with Atrial Fibrillation . . . . . . . . . Level III
Bradley G. Phillips, PharmD, BCPS, FCCP
LEARNING OBJECTIVES
After completing this case study, the reader should be able to:
Determine therapeutic goals for attaining ventricular rate control
or normal sinus rhythm in patients with heart disease presenting
with recurrent paroxysmal atrial fibrillation.
Describe the difference between recurrent paroxysmal and
persistent atrial fibrillation.
Understand the influence of obstructive sleep apnea on the recurrence
and risk of incident atrial fibrillation.
Recognize the importance of identifying and alleviating sleepdisordered
breathing in patients with atrial fibrillation, hypertension
and obstructive sleep apnea.
PATIENT PRESENTATION
Chief Complaint
I feel tired and dizzy during the day, and my heart feels like it is
pumping too fast.
HPI
Mark Finley is a 53-year-old man who presents to the Emergent
Care Clinic with heart palpitations and dizziness. He has a 2-year
history of recurrent paroxysmal atrial fibrillation. He now has
morning headaches and feels tired throughout the day despite
sleeping 78 hours each night. At his last visit 6 months ago he was
in normal sinus rhythm. He has gained 6 kg since his last visit. The
severity of his dizziness fluctuates; the dizziness is worst in the
morning and during exercise. He has been seen by his primary care
provider in the Internal Medicine Clinic for many years for HTN
and recurrent paroxysmal atrial fibrillation.
PMH
HTN (previously well controlled on current antihypertensive regimen)
Recurrent paroxysmal atrial fibrillation (rate controlled)
FH
Both parents had HTN; father had obstructive sleep apnea and died
of an early morning stroke at age 52, mother died in MVA at age 63.
He has one brother who has hypertension.
SH
Mr. Finley manages a local grocery store and lives at home with his
wife. He smoked 1 ppd for 10 years and quit 2 years ago. He drinks
12 glasses of wine each week.
Meds
Lisinopril 20 mg po daily
Metoprolol 50 mg po twice daily
Amlodipine 10 mg po daily
Hydrochlorothiazide 25 mg po daily
Warfarin 5 mg po daily
All
NKDA
ROS
Headache but no blurred vision, chest pain, or fainting spells;
complains of being tired during the day; mild SOB; 2+ pitting
edema
Physical Examination
Gen
Cooperative overweight man in moderate distress
VS
BP 149/84 (supine), P 118 (irregular), RR 20, T 36.3C; Wt 108.3 kg,
Ht 5'11''
Skin
Cool to touch, normal turgor and color


HEENT
PERRLA, EOMI; funduscopic exam reveals mild arteriolar narrowing
but no hemorrhages, exudates, or papilledema
Neck
Large and supple, no carotid bruits; no lymphadenopathy or thyromegaly,
() JVD
Lungs/Thorax
Inspiratory and expiratory wheezes and rales bilaterally no rhonchi
CV
Tachycardia with irregular rate; normal S1, S2; (+) S3; no S4
Abd
NT/ND, (+) BS; no organomegaly, () HJR
Genit/Rect
Stool heme ()
MS/Ext
Pulses 1+ weak, full ROM, no clubbing or cyanosis
Neuro
A & O 3; CN IIXII intact; DTR 2+, negative Babinski



LAB TEST RESULTS




ECG
Atrial fibrillation, ventricular rate 97 bpm, mild LVH
Echo
Evidence of diastolic dysfunction (LVEF 59%, LVEDP 15 mm Hg)
and moderate left atrial enlargement (5.3 cm). No thrombus seen.
Chest X-Ray
Bilateral basilar infiltrates
Assessment
Recurrent paroxysmal atrial fibrillation: moderately symptomatic.
Diastolic heart failure: preserved ejection fraction with increased
LVEDP, pulmonary and peripheral edema; start furosemide.
Possible sleep apnea: schedule sleep study during hospitalization.
HTN: maintain meds for blood pressure control.