Updated: 11/3/2018

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 atrial 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
 
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.CV.21) A 60-year-old male with a past medical history of congestive heart failure presents to his cardiologist with complaints of dyspnea on exertion and palpitations. The EKG strip is shown below. Which of the following is most likely to be spared of infarction? Review Topic

QID: 100537
FIGURES:
1

Heart

22%

(4/18)

2

Cerebral cortex

28%

(5/18)

3

Kidney

6%

(1/18)

4

Liver

39%

(7/18)

5

Spleen

6%

(1/18)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M1.CV.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? Review Topic

QID: 100557
FIGURES:
1

SA node refractory period

0%

(0/9)

2

AV node refractory period

67%

(6/9)

3

Bundle of His conduction speed

11%

(1/9)

4

Purkinje fiber conduction speed

0%

(0/9)

5

Purkinje fiber refractory period

22%

(2/9)

M1

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PREFERRED RESPONSE 2

(M1.CV.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? Review Topic

QID: 100719
1

Atrial fibrillation

84%

(27/32)

2

Transmural myocardial infarction

0%

(0/32)

3

Untreated hypertension

0%

(0/32)

4

Torsades de pointes

6%

(2/32)

5

Ventricular hypertrophy

3%

(1/32)

M1

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PREFERRED RESPONSE 1
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