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Artial Fibrillation
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Atrial fibrillation

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HEART & BLOOD

Cardiovascular System

Atrial fibrillation is an abnormality of heart rhythm in which chambers of the heart contract in a disorganized manner, producing an irregular heart rate. Atrial fibrillation can lead to heart failure (shortness of breath, edema, palpitations) and chest pains and, when left untreated, can lead to stroke. Atrial fibrillation is a common heart arrhythmia. The condition is increasingly common with advancing age. It's not uncommon in people in their 50s and 60s, but it becomes more common in older age groups.

In atrial fibrillation, the heart's two upper chambers (atria) beat chaotically (fibrillate). They also don't beat in coordination with the two lower chambers of the heart (ventricles). The result is an irregular and often rapid heart rate.

Atrial fibrillation is often caused by changes in your heart that occur with age or as a result of heart disease. It may occur sporadically or be a chronic condition.

Although atrial fibrillation usually isn't life-threatening, it can lead to complications such as stroke and congestive heart failure. Treatments for atrial fibrillation are individualized. But they may include medications, surgical procedures and medical devices that help your heart beat more easily.

Signs and symptoms

A heart in atrial fibrillation doesn't beat efficiently. It may not be able to pump an adequate amount of blood out to your body with each heartbeat, causing a drop in your blood pressure.

Although some people with atrial fibrillation have no symptoms, others feel:

  • Weak

  • Lightheaded

  • Short of breath

Atrial fibrillation may also result in these signs and symptoms:

  • A fast pulse

  • Chest pain

  • Palpitations, which are sensations of a racing, uncomfortable, irregular heartbeat or a flopping in your chest

Atrial fibrillation may occur only once in a while, in which case it's called paroxysmal atrial fibrillation. You may have symptoms that come and go, lasting for a few minutes to hours and then stopping on their own. Or you may have chronic atrial fibrillation, in which symptoms last until they're medically treated.

Some people with atrial fibrillation have no symptoms and are unaware of their condition until it's discovered by their doctor during a physical examination. But if you experience frequent palpitations or a fast heart rate, see your doctor.

Causes

To pump blood, your heart muscles must contract and relax in a coordinated rhythm. Contraction and relaxation are controlled by electrical signals that travel through your heart muscles.

Your heart consists of four chambers — two upper chambers (atria) and two lower chambers (ventricles). Within the upper-right chamber of your heart (right atrium) is a group of cells called the sinus node. This is your heart's pacemaker. The sinus node produces the impulse that starts each heartbeat.

Atrial fibrillation involves a disruption of your heart's electrical system, which when functioning properly, sends signals from the sinus node through the atrioventricular (AV) node to the ...

During normal rhythm, the impulse travels first through the atria, then through a connecting pathway between the upper and lower chambers of your heart called the atrioventricular (AV) node. As the signal passes through the atria, they contract, pumping blood from your atria into the ventricles below. A split second later, as the signal passes through the AV node to the ventricles, the ventricles contract, pumping blood out to your body. Each contraction is a heartbeat.

In atrial fibrillation, the upper chambers of your heart (atria) experience chaotic electrical signals. As a result, they quiver. The AV node — the electrical connection between the atria and the ventricles — is overloaded with impulses trying to get through to the ventricles. The ventricles also beat rapidly, but not as rapidly as the atria. The reason is because the AV node is like a highway on-ramp; only so many cars can get on at one time. The result is an irregular and fast heart rhythm. The heart rate in atrial fibrillation may range from 100 to 160 beats a minute. A normal range is 60 to 100 beats a minute.

Abnormalities in the heart's structure are the most common causes of atrial fibrillation. Diseases affecting the heart's valves or pumping system also are likely causes, as is long-term high blood pressure.

However, a third of the people who have atrial fibrillation don't have underlying heart disease. In them, the cause is often unknown. Possible causes include:

  • Damage to the atrial muscle

  • Abnormalities within individual heart cells

  • Emphysema or other lung diseases

  • Exposure to heart stimulants, such as caffeine or tobacco, or to alcohol

  • An overactive thyroid or other metabolic imbalance

  • Rapidly firing triggers, or "hot spots" — often located in the veins that return blood from your lungs to your heart (pulmonary veins) — that cause the atria to fibrillate

Risk factors

The older you are, the greater your risk of atrial fibrillation. As you age, the electrical and structural properties of the atria can change. This may lead to the breakdown of the normal atrial rhythm.

Screening and diagnosis

To make a diagnosis of atrial fibrillation, your doctor may conduct cardiac tests such as the following:

  • Electrocardiogram (ECG). Patches with wires (electrodes) are attached to your skin to measure electrical impulses given off by your heart. Impulses are recorded as waves displayed on a monitor or printed on paper.

  • Holter monitor testing. This is a portable version of an ECG. It's especially useful in diagnosing rhythm disturbances that occur at unpredictable times. The monitor is worn under your clothing. It records information about the electrical activity of your heart as you go about your normal activities for a day or two.

  • Echocardiogram. In this test, sound waves are used to produce a video of your heart. Sound waves are directed at your heart from a wand-like device (transducer), which is held on your chest. The sound waves that bounce off your heart are reflected back through your chest wall and processed electronically to provide video images of your heart in motion.

  • Blood tests. These help your doctor rule out thyroid problems or blood chemistry abnormalities that may lead to atrial fibrillation.

In echocardiography, a wand that generates sound waves is positioned over the heart. This video shows how it works: Reflected sound waves are processed to produce continuous images of the heart ...

Complications

Sometimes, atrial fibrillation can lead to the following complications:

  • Stroke. In atrial fibrillation, blood may pool in your heart and form clots. If a blood clot forms, it might become dislodged from your heart and travel to your brain. There it might block blood flow, causing a stroke. The risk of stroke in atrial fibrillation depends on your age (you have a higher risk as you age) and on whether you have high blood pressure, a history of heart failure, a previous stroke, and on other factors. Depending on your medical condition, your risk of stroke in atrial fibrillation may range from less than 1 percent to more than 10 percent a year. Medications such as blood thinners can greatly lower your risk.

  • Congestive heart failure. Atrial fibrillation may weaken the heart, leading to heart failure — a condition in which your heart can't circulate enough blood to meet your body's needs.

Treatment

Treatments for atrial fibrillation may include medications, surgical procedures and medical devices that help the heart beat more easily. The goals of treating atrial fibrillation include restoring the heart to a normal rhythm (rhythm control), slowing the heart rate (rate control) and preventing blood clots.

Cardioversion: Restoring the heart to a normal rhythm
In order to correct atrial fibrillation — to reset your heart to its regular rhythm (sinus rhythm) — doctors often perform a procedure called cardioversion. This can be done in two ways:

  • Cardioversion with drugs. This uses medications, called antiarrhythmics, that are designed to stop the atria's quivering and restore normal sinus rhythm. Commonly used medications include amiodarone (Cordarone, Pacerone), propafenone (Rythmol), flecainide (Tambocor) and sotalol (Betapace). The drugs effectively maintain sinus rhythm for at least one year in 50 percent to 65 percent of people. However, they can cause side effects such as nausea and fatigue as well as some long-term risks. In rare instances, they may actually cause an increase in heart rate.

  • Electrical cardioversion. This is a brief procedure in which an electrical shock is delivered to your heart through paddles or patches placed on your chest. The shock stops your heart's electrical activity for a split second. When it begins again, it may resume normal rhythm. The procedure is performed under light anesthesia. Beforehand, doctors occasionally prescribe ibutilide (Corvert). This antiarrhythmic medication can improve the procedure's success rate, especially if electrical cardioversion alone hasn't achieved sinus rhythm.

Cardioversion isn't always effective. It may successfully restore regular heart rhythm in more than 90 percent of people, but more than half of those people will eventually go back into atrial fibrillation. In many instances, antiarrhythmic medications are needed indefinitely.

Before undergoing cardioversion, you may be given a blood-thinning medication for several weeks to reduce the risk of blood clots in the atria and the risk of stroke. Alternatively, you may undergo transesophageal echocardiography — a test to exclude the presence of a blood clot — just before cardioversion. In transesophageal echocardiography, a tube is passed down your esophagus and detailed ultrasound images are made of your heart.

Slowing the heart rate
When atrial fibrillation can't be converted, the goal is to slow the heart rate (rate control). Traditionally, doctors have prescribed the medication digoxin (Lanoxin). It can control heart rate at rest but not as well during activity. A newer approach is to use calcium channel blockers or beta blockers. These more consistently control heart rate both at rest and during activity. In general, your heart rate should be under 80 beats a minute when you're at rest, and shouldn't exceed 110 to 120 beats a minute when you're moving moderately, such as with a hallway walk.

Preventing blood clots
You may be at especially high risk of stroke if you have atrial fibrillation and heart disease. In this situation, doctors will likely prescribe blood-thinning medications (anticoagulants), such as warfarin (Coumadin) or aspirin, in addition to medications designed to treat your irregular heartbeat.

Nondrug treatments
In some situations, people with difficult-to-control atrial fibrillation who haven't been helped by other treatments may benefit from more invasive techniques, such as:

  • AV nodal ablation with pacemaker implantation. This involves applying radiofrequency energy to your atrioventricular (AV) node through a long, thin tube (catheter) to destroy this small area of tissue. The procedure prevents the atria from sending too many electrical impulses to the ventricles. The atria continue to fibrillate, though, and anticoagulation medication is still required. In 98 percent of people, this procedure causes a complete block of the heart's electrical impulses. A pacemaker is then implanted to establish a normal rhythm. In a study, 85 percent of people who had this procedure reported improved quality of life and increased ability to exercise.

  • Maze procedure. In this open heart surgery, a maze of incisions made in the atria blocks the flow of excess electrical impulses within the chambers. The surgery has an 80-percent to 90-percent success rate. Some people require a pacemaker after the procedure.

  • Pacemaker implantation. A pacemaker is a medical device that helps regulate the heartbeat. The device, smaller than a matchbox, is placed under the skin near the collarbone. A wire extends from the device to the heart. If a pacemaker detects a heart rate that's too slow or no heartbeat at all, it emits electrical impulses that stimulate your heart to speed up or begin beating again. The most common use of pacemakers is for people with atrial fibrillation in one of two situations. First, if the medications used to prevent atrial fibrillation or control the heart rate lead to excessively slow heartbeats, then you need a pacemaker. Second, pacemakers are needed after AV nodal ablation. For people with occasional atrial fibrillation, new types of pacemakers may help prevent recurrences. These pacemakers eliminate irregular heartbeats that can trigger atrial fibrillation, and can smooth the pulse after atrial fibrillation starts.

  • Pulmonary vein isolation ablation. In many people with atrial fibrillation and an otherwise relatively normal heart, atrial fibrillation is caused by rapidly discharging triggers, or "hot spots." These hot spots are like abnormal pacemaker cells that fire so rapidly that the atria fibrillate. When present, these triggers are most commonly found in the pulmonary veins, the veins that return blood from the lungs to the heart. Catheter ablation (cautery) to electrically isolate the veins can stop them from starting atrial fibrillation. In the procedure, energy is applied through the tip of the catheter at the junction of the pulmonary veins and the left atrium. This eliminates the arrhythmia without the need for medications or implantable devices. This procedure is most likely to work in younger people without significant valvular heart disease and with frequent atrial fibrillation episodes.

Self-care

Many people with atrial fibrillation need to make important lifestyle changes that improve the overall health of their heart. Your doctor may advise that you eat heart-healthy foods, reduce your salt intake — which can help lower blood pressure — increase your physical activity and quit smoking.

Mental stress can exacerbate atrial fibrillation. Taking steps to reduce stress in your life may help calm your nerves — and your heart. Cutting back on caffeine and alcohol, which can over stimulate the heart and trigger an episode of atrial fibrillation, may also be beneficial.

 

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Last Modified : 05/14/08 07:40 AM