Practice Essentials

Atrial fibrillation (AF) has strong associations with other cardiovascular diseases, such as heart
failure, coronary artery disease (CAD), valvular heart disease, diabetes mellitus, and
hypertension. It is characterized by an irregular and often rapid heartbeat (see the image below).
The exact mechanisms by which cardiovascular risk factors predispose to AF are not understood
fully but are under intense investigation. Catecholamine excess, hemodynamic stress, atrial
ischemia, atrial inflammation, metabolic stress, and neurohumoral cascade activation are all
purported to promote AF.

Ventricular rate varies from 130-168

beats per minute. Rhythm is irregularly irregular. P waves are not discernible.
View Media Gallery

Signs and symptoms

The clinical presentation of AF spans the entire spectrum from asymptomatic AF with rapid
ventricular response to cardiogenic shock or devastating cerebrovascular accident (CVA).
Unstable patients requiring immediate direct current (DC) cardioversion include the following:

Patients with decompensated congestive heart failure (CHF)

Patients with hypotension
Patients with uncontrolled angina/ischemia

Initial history and physical examination include the following:

Documentation of clinical type of AF (paroxysmal, persistent, long-standing persistent or

permanent)
Assessment of type, duration, and frequency of symptoms
 Assessment of precipitating factors (eg, exertion, sleep, caffeine, alcohol use)
Assessment of modes of termination (eg, vagal maneuvers)
Documentation of prior use of antiarrhythmics and rate-controlling agents
Assessment of presence of underlying heart disease
Documentation of any previous surgical or percutaneous AF ablation procedures
Airway, breathing, and circulation (ABCs)
Vital signs (particularly heart rate, blood pressure, respiratory rate, and oxygen
saturation)
Evaluation of head and neck, lungs, heart, abdomen, lower extremities, and nervous
system

See Clinical Presentation for more detail.

Diagnosis

Findings from 12-lead electrocardiography (ECG) usually confirm the diagnosis of AF and
include the following:

Typically irregular ventricular rate (QRS complexes)

Absence of discrete P waves, replaced by irregular, chaotic F waves
Aberrantly conducted beats after long-short R-R cycles (ie, Ashman phenomenon)
Heart rate (typically 110-140 beats/min, rarely >160-170 beats/min)
Preexcitation
Left ventricular hypertrophy
Bundle-branch block or intraventricular conduction delay
Acute or prior myocardial infarction (MI)

Transthoracic echocardiography (TTE) is helpful for the following applications:

To evaluate for valvular heart disease

To evaluate atrial and ventricular chamber and wall dimensions
To estimate ventricular function and evaluate for ventricular thrombi
To estimate pulmonary systolic pressure (pulmonary hypertension)
To evaluate for pericardial disease

Transesophageal echocardiography (TEE) is helpful for the following applications:

To evaluate for atrial thrombus (particularly in the left atrial appendage)

To guide cardioversion (if thrombus is seen, cardioversion should be delayed)

See Workup for more detail.

Management
The cornerstones of AF management are rate control and anticoagulation, [1] as well as rhythm
control for those symptomatically limited by AF. The clinical decision to use a rhythm-control or
a rate-control strategy requires integrated consideration of the following:

Degree of symptoms
Likelihood of maintaining sinus rhythm after successful cardioversion
Presence of comorbidities
Candidacy for AF ablation

Anticoagulation

The 2014 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart

Rhythm Society (HRS) guidelines on anticoagulation for patients with nonvalvular AF include
the following [1] :

No risk factors: No anticoagulation or antiplatelet therapy

One moderate-risk factor: Aspirin 81-325 mg/day, or anticoagulants
Any high-risk factor or more than one moderate-risk factor: Anticoagulants

Risk factors for thromboembolism in AF are as follows:

High-risk factors: Prior stroke or transient ischemic attack (TIA), systemic

thromboembolism, or age 75 years or older
Moderate-risk factors: Age 65-74 years, female sex, hypertension, diabetes mellitus, heart
failure, arterial disease (prior myocardial infarction, peripheral arterial disease, aortic
plaque)

Anticoagulation is indicated as follows:

Patients with newly diagnosed AF and those awaiting electrical cardioversion can be
started on intravenous (IV) heparin or low-molecular-weight heparin (LMWH) (1 mg/kg
twice daily)
Concomitantly, patients can be started on warfarin in an inpatient setting while awaiting a
therapeutic international normalized ratio (INR) value of 2-3
Newer oral anticoagulants present an alternative to warfarin in patients with nonvalvular
AF; their onset of action is almost immediate and eliminates the need for bridging with
heparin/LMWH.

Newer oral anticoagulants that have been approved by the US Food and Drug Administration
(FDA) include the following:

One direct thrombin inhibitor: Dabigatran

Three factor Xa inhibitors: Rivaroxaban, apixaban, edoxaban

Risk of bleeding
Optimal long-term strategies for AF management should be based on a thoroughly integrated
consideration of patient-specific factors and the likelihood of success. Selection of an appropriate
antithrombotic regimen should be balanced between the risk of stroke and the risk of bleeding.

Factors that increase the risk of bleeding with anticoagulation include the following:

History of bleeding (the strongest predictive risk factor)

Age older than 75 years
Liver or renal disease
Malignancy
Thrombocytopenia or aspirin use
Hypertension
Diabetes mellitus
Anemia
Prior stroke
Fall risk
Genetic predisposition
Supratherapeutic INR (for warfarin)

For patients with clinical indications for anticoagulation who are at an unacceptably high risk of
clinically significant bleeding, two treatment alternatives exist:

Left atrial appendage isolation using the catheter-based WATCHMAN device (the only
FDA device currently approved in the United States)
Left atrial appendage ligation using the LARIAT epicardial/endocardial suture system

Rate control strategies

Medications (non-dihydropyridine calcium channel blockers, beta-blockers, digoxin

[rarely as monotherapy], amiodarone [mainly for patients who are intolerant of, or
unresponsive to, other agents])
Atrioventricular node modification with placement of a permanent pacemaker (invasive
procedure indicated in patients when other rate and rhythm control alternatives have been
exhausted)

Rhythm control strategies

Electrical cardioversion (generally employed as a the first-line management strategy in

young symptomatic patients)
Medications (flecainide, propafenone, dofetilide, amiodarone, sotalol)
Ablation (catheter based, surgical, or hybrid)

Catheter ablation is recommended in the 2014 ACC/AHA/HRS AF guidelines for the following
indications [1] :
 It is useful for patients with symptomatic paroxysmal AF who are intolerant of, or whose
condition is refractory to, rhythm-control medications.
It is reasonable as a treatment for patients with symptomatic persistent AF who are
intolerant of, or whose condition is refractory to, a rhythm-control strategy using
medications.
It is a reasonable alternative for patients with recurrent symptomatic paroxysmal AF who
have not tried a rhythm-control medication.

Praktek Essentials

Atrial fibrillation (AF) memiliki hubungan yang kuat dengan penyakit kardiovaskular lainnya, seperti
gagal jantung, penyakit arteri koroner (CAD), penyakit jantung katup, diabetes melitus, dan hipertensi.
Hal ini ditandai dengan detak jantung yang tidak teratur dan seringkali cepat (lihat gambar di bawah).
Mekanisme yang tepat dimana faktor risiko kardiovaskular menjadi predisposisi AF tidak sepenuhnya
dipahami namun berada dalam penyelidikan intensif. Kelebihan katekolamin, stres hemodinamik,
iskemia atrium, peradangan atrium, tekanan metabolik, dan aktivasi kaskade neurohumoral semuanya
dimaksudkan untuk mempromosikan AF.
Tingkat ventrikel bervariasi dari 130-168 denyut per menit
Tingkat ventrikel bervariasi dari 130-168 denyut per menit. Irama tidak beraturan. Gelombang P tidak
dapat dilihat.
Lihat Galeri Media
Tanda dan gejala

Presentasi klinis AF mencakup keseluruhan spektrum dari AF asimtomatik dengan respon ventrikel yang
cepat terhadap syok kardiogenik atau kerusakan serebrovaskular (CVA) yang menghancurkan. Pasien
yang tidak stabil yang membutuhkan kardioversi langsung langsung (DC) adalah sebagai berikut:

Pasien dengan dekompensasi gagal jantung kongestif (CHF)

Penderita hipotensi
Pasien dengan angina / iskemia tidak terkontrol

Riwayat awal dan pemeriksaan fisik meliputi:

Dokumentasi tipe klinis AF (paroxysmal, persistent, lama bertahan atau permanen)

Penilaian jenis, durasi, dan frekuensi gejala
Penilaian faktor pengendapan (misalnya, tenaga, tidur, kafein, penggunaan alkohol)
Penilaian mode penghentian (misalnya, manuver vagal)
Dokumentasi penggunaan antiaritmia dan agen pengendali tingkat sebelumnya
Penilaian adanya penyakit jantung yang mendasarinya
Dokumentasi prosedur ablasi bedah atau percutaneous AF sebelumnya
Airway, pernapasan, dan sirkulasi (ABC)
Tanda vital (terutama detak jantung, tekanan darah, laju pernafasan, dan saturasi oksigen)
Evaluasi kepala dan leher, paru-paru, jantung, perut, ekstremitas bawah, dan sistem saraf

Lihat Presentasi Klinis untuk lebih detail.

Diagnosa

Temuan dari elektrokardiografi 12 timbal (EKG) biasanya mengkonfirmasi diagnosis AF dan mencakup
hal berikut:

Biasanya tingkat ventrikel tidak teratur (kompleks QRS)

Tidak adanya gelombang P yang diskrit, digantikan oleh gelombang F yang tidak beraturan dan kacau
Aberrantly melakukan beat setelah siklus R-R yang pendek (yaitu fenomena Ashman)
Detak jantung (biasanya 110-140 denyut / menit, jarang> 160-170 denyut / menit)
Preexcitation
Hipertrofi ventrikel kiri
Bundel-cabang blok atau penundaan konduksi intraventrikular
Infark miokard akut atau sebelumnya (MI)

Echocardiography Transthoracic (TTE) sangat membantu untuk aplikasi berikut:

Mengevaluasi penyakit jantung katup

Mengevaluasi ruang atrium dan ventrikel dan dimensi dinding
Mengestimasi fungsi ventrikel dan mengevaluasi trombi ventrikel
Untuk memperkirakan tekanan sistolik paru (pulmonary hypertension)
Mengevaluasi penyakit perikardial

Ekokardiografi transesofagus (TEE) sangat membantu untuk aplikasi berikut:

Mengevaluasi trombus atrium (terutama pada atase atrium kiri)

Untuk memandu kardioversi (jika trombus terlihat, kardioversi harus ditunda)

Lihat Workup untuk detail lebih lanjut.

Pengelolaan

Landasan manajemen AF adalah kontrol tingkat dan antikoagulan, [1] serta kontrol irama untuk mereka
yang dibatasi secara simetris oleh AF. Keputusan klinis untuk menggunakan kontrol ritme atau strategi
pengendalian tingkat memerlukan pertimbangan terpadu sebagai berikut:

Derajat gejala
Kemungkinan mempertahankan ritme sinus setelah berhasil kardioversi
Adanya komorbiditas
Kandidat ablasi AF

Antikoagulan

Pedoman American College of Cardiology (ACC) / American Heart Association (AHA) / Heart Rhythm
Society (HRS) tahun 2014 tentang antikoagulan untuk pasien dengan AF nonvalvular meliputi:

Tidak ada faktor risiko: Tidak ada antikoagulan atau terapi antiplatelet
Satu faktor risiko sedang: Aspirin 81-325 mg / hari, atau antikoagulan
Faktor risiko tinggi atau lebih dari satu faktor risiko sedang: Antikoagulan

Faktor risiko tromboemboli di AF adalah sebagai berikut:

Faktor risiko tinggi: Sebelum stroke atau transient ischemic attack (TIA), tromboemboli sistemik, atau
usia 75 tahun atau lebih
Faktor risiko sedang: Usia 65-74 tahun, jenis kelamin perempuan, hipertensi, diabetes mellitus, gagal
jantung, penyakit arteri (sebelum infark miokard, penyakit arteri perifer, plak aorta)

Antikoagulan diindikasikan sebagai berikut:

Pasien dengan AF yang baru didiagnosis dan mereka yang menunggu kardioversi listrik dapat diawali
dengan heparin intravena (IV) heparin atau heparin dengan berat molekul rendah (LMWH) (1 mg / kg
dua kali sehari)
Dengan bersamaan, pasien dapat memulai warfarin di tempat rawat inap sambil menunggu rasio rasio
normalisasi terapeutik (INR) 2-3
Antikoagulan oral baru hadir sebagai alternat
Lawrence Rosenthal,
Apr 10, 2017

Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman,
MD more...

http://emedicine.medscape.com/article/151066-overview