CCMS Medicine Spring 2017 - 9

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pathway where immediate risk to life can occur if not managed
appropriately since the accessory pathway may allow many
more impulses to reach the ventricle. Atrial flutter has organised
electrical activity but discharging very rapidly and producing
sawtooth appearances.
Primary pathological change seen is progressive fibrosis of the atria
caused primarily by dilatation but genetic causes and inflammation
can also result in fibrosis. Dilatation can occur in any number of
conditions including valvular disease, hypertension, ischemia, and
CHF. Inflammation like autoimmune disorders can also cause
afib. Endocrine disorders such as thyroid can also affect electrical
activity as can electrolyte imbalances.

Workup includes all potential causes.
* A good history and physical exam is crucial.
* Lab work should include electrolytes, thyroid profiles, and
CBC.
* Echocardiography, both transthoracic or transesophageal,
is probably the most important tool, especially to assess
chamber size (to assess atrial size and rule out thrombus) and
valvular disease.
* Evaluation of coronary anatomy may be needed if ischemia
is of concern.
I have outlined the major workup but depending on consequences
a more extensive workup may be needed.

Causes

Consequences

Up to 30% of AF can be idiopathic but extensive workup may
reveal a cause. Major causes are listed below.
* Valvular disease, especially mitral valve disease
* Hypertension
* Congestive Heart Failure
* Idiopathic Heart Disease
* Cardiomyopathy
* Pericarditis
* Heart surgery
* Congenital and genetic factors
* Pulmonary causes including pneumonia and pulmonary
embolism, sarcoidosis, and Chronic Obstructive Pulmonary
Disease
* Sleep apnea
* Obesity
* Endocrine disorders, especially thyroid
* Alcohol can present as holiday heart syndrome
* Autoimmune disorders
These are just some of the potential causes of AF.

Diagnosis and workup

AF is typically diagnosed via an ECG, where disorganised rhythm
is easily seen; the problem occurs when there is a suspicion of
paroxysmal AF that is not seen during a routine visit. Then one
may require a holter monitor, event recorder, or even, rarely, a loop
recorder, especially if occult stroke is seen.

* AF can be devastating; stroke is the most dangerous
complication and rates of stroke over the age of eighty can be
as high as 25% annually. The death rate is doubled in AF. In
2013, 112,000 deaths were attributed to AF and aflutter. This
is a significant increase from 1999 when 29,000 people died
from AF related complications.
* Development of cardiomyopathy and CHF is not
uncommon.
* Impact on lifestyle is significant, with diminished exercise
capacity and work days lost affecting economy.
TO BE CONTI N U E D
This article was a
collaboration between
Mian A. Jan, an
interventional cardiologist
practicing in Chester County,
and Zarshawn Jan, a thirdyear medical student at
Drexel University College
of Medicine.

SPRING 2017 | CHESTER COUNTY MEDICINE 9
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