Updated: 11/13/2020

Atrial Arrhythmias

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Snapshot
  • A 66-year-old man presents to the emergency deparment with palpitations and lightheadedness. The patient has been experiencing these symptoms for the past few days. He reports mild chest discomfort. Medical history is significant for hypertension, type 2 diabetes mellitus, and rheumatic heart disease. An electrocardiogram is immediately performed, which demonstrates a narrow QRS complex tachyarrhythmia that is irregularly irregular. (Atrial fibrillation)
Introduction
  • Aberrant rhythms can occur anywhere along the cardiac conduction system (SA node to a single cardiomyocyte)
    • these aberrant rhythm can originate from the
      • atrium (thus a supraventricular arrhythmia)
      • ventricles
  • Etiology
    • there are a number of causes and they include
      • myocardial infarction
        • cardiac scarring can interrupt the cardiac conduction system
      • atrial stretch
        • alters the cardiac conduction system (e.g., significant mitral stenosis)
  • Symptoms
    • asymptomatic
    • palpitation
    • light headedness
    • syncope
    • sudden cardiac death
 
Atrial Arrhythmias
Type
Electrocardiogram Findings
Treatment Comments
Atrial fibrillation
  • A tachyarrhythmia that is irregularly irregular rhythm and has absent P-waves
  • Stable patients
    • rate control
      • e.g., β-blockers and nondihydropyridine calcium channel blocker
    • rhythm control
      • e.g., amiodarone
  • Unstable patients
    • synchronized cardioversion
  • Anticoagulation
    • options include
      • aspirin
      • warfarin
      • new oral anticoagulant (NOAC)
        • e.g., dabigatran
  • Most common type of atrial arrhythmia
  • A dilated left atrium can result in atrial fibrillation
    • e.g., mitral stenosis
  • Can result in a thromboembolic event (e.g., stroke) 
  • The ventricular rate is determined by the AV node refractory period  
  • Often originates in the pulmonary veins
Atrial flutter
  • A tachyarrhythmia with a "sawtooth" appearance 
  • Stable patients
    • treat similarly as atrial fibrillation
  • Unstable patients
    • synchronized cardioversion
  • Definitive treatment is with catheter ablation
  • Caused by a re-entrant circuit in the right atrium
Sick sinus syndrome 
  • A bradyarrhythmia with episodes of tachycardia
  • acute patients
    • assess for reversible causes such as medications (calcium channel blockers, digoxin, lithium)
  • chronic patients
    • anticoagulation
    • pacemaker placement
 
 
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Questions (4)
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(M1.CV.13.41) A 28-year-old woman presents to the urgent care center complaining of weakness, confusion, and that her heart is "racing and flopping" in her chest. She has no significant past medical history. She denies any previous episodes of anxiety attacks or heart issues. She smokes 1/2 of a pack of cigarettes per day and is a social drinker. She denies the use of any illicit drugs. She has no known drug allergies, and she does not take any medications on a daily basis. An EKG is ordered and is shown in Figure A. This patient's ventricular contraction rate is determined by which of the following? Tested Concept

QID: 100557
FIGURES:
1

SA node refractory period

4%

(3/80)

2

AV node refractory period

61%

(49/80)

3

Bundle of His conduction speed

16%

(13/80)

4

Purkinje fiber conduction speed

8%

(6/80)

5

Purkinje fiber refractory period

11%

(9/80)

M 1 E

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(M1.CV.12.203) A 60-year-old male presents with palpitations. He reports drinking many glasses of wine over several hours at a family wedding the previous evening. An EKG reveals absent P waves and irregularly irregular rhythm. He does not take any medications. Which is most likely responsible for the patient’s symptoms? Tested Concept

QID: 100719
1

Atrial fibrillation

95%

(95/100)

2

Transmural myocardial infarction

0%

(0/100)

3

Untreated hypertension

0%

(0/100)

4

Torsades de pointes

2%

(2/100)

5

Ventricular hypertrophy

1%

(1/100)

M 2 E

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Topic COMMENTS (7)
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