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Atrial fibrillation is the most common chronic arrhythmia, with an incidence and prevalence that rise with age, so that it affects nearly 10% of individuals over age 80 years It occurs in rheumatic and other forms of valvular heart disease, dilated cardiomyopathy, ASD, hypertension, and coronary heart disease as well as in patients with no apparent cardiac disease; it may be the initial presenting sign in thyrotoxicosis, and this condition should be excluded with the initial episode The heart rate may range from quite slow to extremely rapid, but is uniformly irregular unless underlying complete heart block and a permanent ventricular pacemaker is in place The surface ECG typically demonstrates erratic, disorganized atrial activity between discrete QRS complexes occurring in an irregular pattern The atrial activity may be very fine and difficult to detect on the ECG, or quite course and often mistaken for atrial flutter Atrial fibrillation often appears paroxysmally before becoming the established rhythm Pericarditis, chest trauma, thoracic or cardiac surgery, thyroid disorders, or pulmonary disease (as well as medications such as theophylline and -adrenergic agonists) may cause attacks in patients with normal hearts Acute alcohol excess and alcohol withdrawal and, in predisposed individuals, even consumption of small amounts of alcohol may precipitate atrial fibrillation This latter presentation, which is often termed holiday heart, is usually transient and self-limited Short-term rate control usually suffices as treatment Perhaps the most serious consequence of atrial fibrillation is the propensity for thrombus formation due to stasis in the atria (particularly the left atrial appendage) and consequent embolization, most devastatingly to the cerebral circulation Overall, the rate of stroke is approximately 5 events per 100 patient-years of follow-up However, patients with significant obstructive valvular disease, chronic heart failure or LV dysfunction, diabetes, hypertension, or age over 75 years and those with a history of prior embolic events are at substantially higher risk (up to nearly 20 events per 100 patient-years in patients with multiple risk factors) (Table 10 9) A simple score derived from the Framingham study to estimate risk of stroke is available for PDA download at http:// wwwstatcodercom/a-fib_strokehtm.

Data derived from collaborative analysis of five untreated control groups in primary prevention trials As a group, patients with nonvalvular atrial fibrillation have about a sixfold increased risk of thromboembolism compared with patients in normal sinus rhythm TIA, transient ischemic attack Reproduced, with permission, from ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation 2006, American Heart Association, Inc

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Atrial fibrillation itself is rarely life-threatening; however, it can have serious consequences if the ventricular rate is sufficiently rapid to precipitate hypotension, myocardial ischemia, or tachycardia-induced myocardial dysfunction Although many patients particularly older or inactive individuals have relatively few symptoms if the rate is controlled, some patients are aware of the irregular rhythm and may find it as very uncomfortable Most patients will complain of fatigue whether they experience other symptoms or not Atrial fibrillation is the only common arrhythmia in which the ventricular rate is rapid and the rhythm very irregular Because of the varying stroke volumes resulting from varying periods of diastolic filling, not all ventricular beats produce a palpable peripheral pulse The difference between the apical rate and the pulse rate is the pulse deficit ; this deficit is greater when the ventricular rate is high

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1 Initial management a Hemodynamically stable patient If, as is often the case particularly in older individuals the patient has no symptoms, hemodynamic instability, or evidence of important precipitating conditions (such as silent myocardial infarction or ischemia, decompensated heart failure, pulmonary embolism, or hemodynamically significant valvular disease), hospitalization is usually not necessary In most of these cases, atrial fibrillation is an unrecognized chronic or paroxysmal condition and should be managed accordingly (see below) For new onset atrial fibrillation, thyroid function tests and assessment for occult valvular or myocardial disease should be performed b Hemodynamically unstable patient If the patient is hemodynamically unstable usually as a result of a rapid ventricular rate or associated cardiac or noncardiac condi-

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