case presenation

heart arrythmia

Chief complaints (CC)
Intermittent sensation of fluttering in the chest,

Palpitation

History of present illness (HPI)
A 66 year-old man comes to the emergency department complaining of a several-day history of an intermittent sensation of fluttering in the chest. He feels weak when the episodes occur but denies chest pain or shortness of breath.
Past medical history (PMHx)
He has had hypertension for 20 years
asthma from chlidhood
Allergies
None known
Current medications
Enalapril
Albuterol
Social history (SocHx)
Non smoker, bowel and dietary habits normal. He denies any alcohol use.
Family history (FHx)
Father died at 82, Vesical tumor
Mother died at 76, Stroke
Physical examination (PE)
Examination female with average height and built lying on bed conscious and oriented. Temperature 36.8C , Blood pressure 140/80, pulse 140/min, respirations 12/min PE: supple neck, no jugular vein distension or thyromegaly.
Extremities: no edema, no palpable lymph nodes
Pulses equally palpable on both sides, normal volume No radio femoral delay No lower limb or sacral edema No rashes
Cardiovascular examination Apex beat in 5th intercostal space at mid clavicular line, non sustained. irregularly irregular rhythm with no rubs or gallops.
Respiratory system Chest bilaterally symmetrical moving with respiration. Vesicular breathing No crepits or ronchi respiration 26 times per minute
Gastrointestinal system No hepatosplenomegaly Central Nervous System Normal sensory and motor exam.
Laboratory results (Lab)
Na+ 139 mEq/L, K+ 4.4 mEq/L, Cl-: 108mEq/L, complete bload count=CBC in normal range
Other investigations
ECG: shows a rhythm disturbance, atrial fibrilation Thyroid Function tests within normal limits
Cardiac enzymes normal
Echocardiogram Normal Ejection fraction, left atrial enlargement
ABGA within normal limit
Differential diagnosis
Atrial Fibrillation
Multifocal atrial tachycardia
Supraventricular tachycardia
Pulmonary Embolism
Thyrotoxicosis
Case summary and impression
Summary 41 years old male presented with history of retrosternal chest pain, severe continuous for 4 hours then decrease in intensity associated with nausea.
Treatment
GOALS
Hemodynamic stabilization
Ventricular rate control
Prevention of embolic complication

Medical Options

  • Cardiac rate control: The first treatment goal is to slow down the ventricular rate, if it is fast.
    • If patients experience serious clinical symptoms, such as chest pain or shortness of breath related to the ventricular rate, the health care professional in the emergency department will try to decrease the heart rate rapidly with intravenous (IV) medications.
    • If patients have no serious symptoms, they may be given medications by mouth.
    • Sometimes patients may require more than one type of oral medication to control the heart rate.
  • Restore and maintain normal cardiac rhythm: About half of the people with newly diagnosed atrial fibrillation will convert to normal rhythm spontaneously in 24-48 hours. However, atrial fibrillation typically returns in many patients.
    • As already mentioned, not everyone with atrial fibrillation needs to take medication to maintain normal rhythm.
    • The frequency with which arrhythmia returns and the symptoms it causes partly determine whether individuals receive rhythm-controlling medication, which is usually termed antiarrhythmia medication.
    • Medical professionals tailor each person's antiarrhythmia medication(s) carefully to produce the desired effect, a normal cardiac rhythm.
    • Most of these medications cause unwanted side effects, which limit their use. These medications should be discussed with a doctor.
  • Prevent clot formation (strokes): Strokeis a devastating complication of atrial fibrillation. Blood clots can form in the atria when their motility is impaired as in A fib. Stroke can occur when a piece of a blood clot formed in the heart breaks off and travels to the brain, where it blocks blood flow.
    • Coexisting medical conditions, such as hypertension, congestive heart failure, heart valve abnormalities, or coronary heart disease, significantly increase the risk of stroke. Age older than 65 years also increases the risk of stroke.
    • Most people with atrial fibrillation take a blood-thinning drug called warfarin (Coumadin) to lower this risk of stroke and heart failure. Warfarin blocks certain factors in the blood that promote clotting. Acutely, the initial blood thinner is IV or subcutaneous heparin to thin a patient's blood rapidly. Then a decision is made whether they need oral warfarin.
    • People at lower risk of stroke and those who cannot take warfarin may use aspirin. It may be used in conjunction with Plavix. Aspirin is not without its own side effects, including bleeding problems and stomach ulcers.
    • Clopidogrel (Plavix) is another medication that is also used by many physicians to prevent clot formation in cardiovasular diseases, including A fib.
    • Other drugs that may be used by some cardiologists include Lovenox, Pradaxa, and Xarelto. The choice of these drugs which are used to reduce the chance of clot formation in patients with chronic A fib is often determined by the patient's problems with Coumadin and the preference or experience of the cardiologist with these drugs.
Follow up

If patients have no other ongoing heart problems and medications succeed in controlling the patient's heart rate, the patient may be sent home from the emergency department. This is often done after consultation with the patient's doctor or cardiologist. Patients should follow-up with their health care professional within 48 hours.

If the heart rhythm does not convert to normal by itself, the patient may need electrical cardioversion, or defibrillation.

  • Patients in atrial fibrillation longer than 48 hours may need three weeks of treatment with an anticoagulant medication, such as warfarin, before cardioversion and usually for at least four weeks after.
  • Anyone with underlying heart disease or those that do not respond to rate-controlling treatment may require hospitalization and a consult with a cardiologist.
  • Patients undergoing surgery (pacemaker implantation) may require rehabilitation.
Long-Term Medications
  • Miscellaneous antiarrhythmia medications: These drugs control the heart rhythm rather than the rate. They reduce the frequency and duration of atrial fibrillation episodes. They are often given to prevent the return of atrial fibrillation after cardioversion. The most commonly used drugs are amiodarone (Cordarone, Pacerone), sotalol (Betapace), propafenone(Rythmol), and flecainide (Tambocor). Overall, these drugs are 50%-70% effective.
  • Beta-blockers: These drugs slow the heart rate by decreasing the rate of the SA node and by slowing conduction through the AV node. Therefore, the heart's demand for oxygen is decreased, and the blood pressure is stabilized. Examples includeesmolol (Brevibloc), atenolol (Tenormin),propranolol (Inderal), or metoprolol(Lopressor, Toprol XL).
  • Calcium channel blockers: These drugs also slow heart rate by mechanisms similar to those of beta-blockers. Verapamil(Calan, Isoptin) and diltiazem (Cardizem) are examples of calcium channel blockers.
  • Digoxin (Lanoxin): This drug decreases the conductivity of electrical impulses through the AV node, but onset of action is slower than beta-blockers and calcium blockers. Digoxin is currently used primarily in patients with associated heart disease, such as a poorly functioning left ventricle.
  • Dofetilide (Tikosyn): This is an oral antiarrhythmic drug that must be initiated in the hospital over a three-day period. Hospitalization is needed to closely monitor the heart rhythm during the initial dosing period. If the atrial fibrillation responds favorably during the initial dosing, a maintenance dose is established to be continued at home.
  • Other medications: There are many other drugs in use and they are prescribed to individualize the treatment of A fib. Other drugs can include Ibutilide (Corvert), Dronedarone (Multaq), and Quinidine(Cardioquin, Quinalan, Quinidex, Quinaglute); others may be used rarely.
  • Herbs: Some herbal companies claim cures of atrial fibrillation with their product, but the data to support these claims is questionable and not acceptable to most researchers.
  • Warfarin (Coumadin): This drug is an anticoagulant (blood thinner). It reduces the ability of the blood to clot. It lowers the risk of an unwanted blood clot forming in the heart or in a blood vessel. Atrial fibrillation increases the risk of forming such blood clots. It is extremely important to follow the exact dosing prescribed and to have regular blood tests (International Normalized Ratio [INR]) when recommended by the doctor. Patients are urged to keep these important appointments to reduce their risk of blood clot formation or the risk of having an excessive tendency to bleed.
  • Eliquis: This new drug, reported to be better than warfarin for A fib treatment, has been delayed in its FDA approval.
  • Aspirin and clopidogrel (Plavix): These are two commonly prescribed drugs used to reduce the chance of clot development in A fib patients, especially if patients cannot tolerate Coumadin; they also have been used in short-term treatments while a patient is undergoing evaluation for clot formation.
  • Heparin and enoxaparin (Lovenox): These similar drugs have been used in short-term treatment of A fib patients; occasionally, Lovenox has been used by some physicians for longer term treatment.
  • Dabigatran (Pradaxa): This thrombin inhibitor is approved for prevention of strokes and thrombus in nonvalvular A fib. There is some controversy about this new drug causing increased heart problems.
  • Rivaroxaban (Xarelto): This factor Xa inhibitor is approved for the prevention of strokes and embolisms associated with nonvalvular A fib; dosing is related to creatinine clearance (CrCl) levels (kidney function).
Discussion
Cardioversion (also termed defibrillation): This technique uses electrical current to "shock" the heart back to normal sinus rhythm with an electrical current. This is sometimes called DC cardioversion. Prior to cardioversion, many patients undergo a sonogram of the heart to determine if any clots are present.
Pacemaker: A pacemaker is an electronic device that prevents slow heartbeats and may reduce the likelihood of atrial fibrillation in a small number of patients. The artificial pacemaker takes the place of the "natural pacemaker," the SA node, supplying electrical impulses to keep the heart beating in a normal rhythm when the SA node no longer can.

in brief

Patient 65 years, Female