In medical practice, there are situations when an individual's heart beats quite often, and the reason for this phenomenon lies not in a stressful situation, but in a permanent type of atrial fibrillation. In the case history, this pathology is indicated by code I 48, according to the ICD of the tenth revision. This anomaly is considered life-threatening, since in about thirty percent of cases it leads to a failure of cerebral circulation, i.e., a stroke. At the same time, more and more such patients are registered every year. This is due to an increase in life expectancy, including older individuals with such a diagnosis.
Atrial flutter and fibrillation: what's the difference?
Failure of the heart rhythm, in which muscle fibers contract chaotically and at a tremendous frequency, reaching up to six hundred beats per minute, is called atrial fibrillation. Externally, this process is manifestedfrequent pulse, but it is very difficult to probe. It looks like it's flickering. Thanks to this unusual comparison, the disease received a second name - atrial fibrillation.
Flutter is considered a milder variation of arrhythmia. In this case, the heart rate reaches four hundred beats per minute, but the heart beats at regular intervals.
Quite often, these two rhythm disturbances are identified, but this cannot be done, since the manifestations and genesis of these failures are different, which is necessarily reflected in the case histories. Atrial fibrillation is a random contraction of heart muscle cells at irregular intervals, as well as the presence of several foci that are located in the left atrium and send extraordinary abnormal discharges. The flutter is carried out at regular intervals due to the coordinated contraction of the muscles, since the impulses come from only one focus.
Classification of atrial fibrillation
Let's consider the systematizations used by practicing doctors. The form of atrial fibrillation is divided into:
- First identified - currently diagnosed and no further mention of her discovery. This type is asymptomatic and symptomatic, paroxysmal or persistent.
- Persistent - fibrillation lasts more than a week. It is quite difficult to differentiate this and the paroxysmal form in practice.
- Long-term persistent, or it is also called stable, worries the patient infor a year or more. A pronounced clinical picture is observed only during physical exertion.
- The paroxysmal form of atrial fibrillation in the case history indicates its sudden appearance and spontaneous disappearance within two days. If the attacks last up to seven days, then they are also referred to this form of the disease. The patient feels periodic failures in the work of the heart, which are accompanied by weakness, pressure drops, shortness of breath, dizziness and retrosternal pain. In rare cases, a fainting state occurs.
- Long persistent ailment - persistent atrial fibrillation. The medical history records a mutual decision (doctor and patient) that no attempt will be made to restore normal sinus rhythm. With the consent of the individual, that is, when he changed his mind, measures are taken to control the rhythm. In this case, the arrhythmia again becomes protracted persistent.
Clinical classification or by cause. According to this systematization, atrial fibrillation is distinguished by concomitant diseases or conditions that increase the risk of arrhythmia. Consider the types of fibrillations:
- Secondary - provocateurs are heart disease.
- Focal - common in young patients, especially those with a history of atrial tachycardia or short-term episodes of fibrillation.
- Polygenic - formed against the background of multiple gene mutations at a fairly early age.
- Monogenic - occurs with a single gene mutation.
- Postoperative - open cardiac surgery acts as a provocateur.
- In professional athletes - occurs in paroxysms and depends on intense and long workouts.
- In patients with valvular anomalies - formed after operations to correct the valvular apparatus, as well as with mitral stenosis.
According to severity. The EAPC scale, it is used to assess the quality of life:
- 1 - no symptoms of the disease.
- 2a - minor manifestations, no threat to the individual.
- 2b - Palpitations and shortness of breath are felt, but the ability to perform daily activities is not lost.
- 3 - pronounced signs of arrhythmia: weakness, palpitations, shortness of breath.
- 4 - the ability to serve oneself is lost.
Prevalence. Genetic Aspects
According to the analysis of medical records, or rather, case histories, coronary artery disease and tachysystolic atrial fibrillation occur in individuals from twenty years of age and older, i.e., approximately three percent of the adult population. The explanation for this fact is as follows:
- early detection;
- the occurrence of concomitant diseases that provoke the appearance of atrial fibrillation;
- increased life expectancy.
In addition, it was found that the risk of getting sick is higher in men, but the fair sex is more susceptible to stroke, as they have many comorbidities and a pronounced clinical picture of heart rhythm failure.
Proved that the basis of the disease is a mutationgenes, i.e. an individual, even in the absence of concomitant cardiovascular risks, is at great risk of developing atrial fibrillation. Doctors know about fourteen variants of changes in the genotype that lead to rhythm failure.
Diagnosis
Before making a diagnosis of atrial fibrillation, the doctor enters an anamnesis into the medical history, where the following information will be important information:
- presence of abnormalities of the thyroid gland, gastrointestinal tract, lungs and others;
- have close relatives had similar arrhythmias;
- women experience menopause;
- if the patient himself noticed rhythm disturbances, the doctor will be interested in how long they last.
Next is a physical examination. With its help, the doctor also conducts differential diagnosis with trembling. When listening, the heart rate will differ from the pulse rate at the wrist. The conclusion about the regularity of the rhythm is made according to the results of the ECG, which is considered a particularly informative diagnostic method. All information received is also recorded in the medical history. When examining elderly individuals, an electrocardiogram is necessarily shown. This measure reduces the number of patients who subsequently develop acute heart failure and ischemic stroke, as well as improve the diagnosis of asymptomatic and paroxysmal forms of fibrillation. To diagnose the latter, it is best to resort to round-the-clock Holter monitoring.
Now there are innovative methods by which individuals can independently identify violations. However, in terms of informativeness, they are inferior to the cardiogram.
Treatment measures
After the diagnosis of atrial fibrillation is made, complex treatment is carried out. This takes into account factors such as:
- symptoms;
- blood pressure numbers;
- heart rate;
- danger of cerebrovascular accident;
- probability of sinus rhythm recovery;
- presence of concomitant pathology aggravating the course of arrhythmia.
After assessing the patient's condition, the doctor decides on the tactics of his management.
For the prevention of stroke are shown:
- Warfarin;
- Dabigatran, Apixaban.
To control the heart rate, the following strategies are followed:
- heart rate control;
- resuming natural sinus rhythm.
Of course, the choice of tactics for the treatment of atrial fibrillation depends on a number of reasons - this is the pathology experience, the severity of symptoms, the presence of serious concomitant ailments, age, and more. In elderly patients, the first strategy is most often used. Thanks to this approach, the manifestations of the disease are reduced, and the activity of patients in daily life improves.
Verapamil, Diltiazem and Bisoprolol are the drugs of choice for rapidly reducing heart rate. When arrhythmia is combined with cardiacinsufficiency shows combinations of beta-blockers with digitalis derivatives - Digoxin. For individuals with unstable blood pressure, intravenous administration of Amiodarone is recommended.
Use for permanent reception:
- Beta-blockers - Carvedilol, Metoprolol, Nebivolol. They are well tolerated regardless of age.
- "Digoxin". It is important to choose the right dosage due to toxicity.
- Reserve medicine - Amiodarone.
Thus, in case of a disease - atrial fibrillation - to achieve the target level (110 beats per minute) of heart rate, the choice of drugs is carried out individually. Initially, a minimum dose is recommended, which is then gradually increased until a therapeutic effect is obtained.
Percutaneous catheter ablation has been proven to be effective in the treatment of atrial fibrillation, and especially in reducing symptoms. The use of this method, together with the latest anticoagulants and new generation antiarrhythmic drugs, significantly improves the prognosis. Treatment for atrial fibrillation is:
- taking anticoagulants;
- correction of cardiovascular pathology;
- symptom relief.
According to the latest clinical guidelines, the treatment of atrial fibrillation is based on new approaches to antiarrhythmic therapy. To reduce the frequency of atrial fibrillation or limit its manifestations, various non-drug interventions are actively used.
Emergency cardioversion
In another way, it is also called electropulse therapy - this is a manipulation with which it is possible to restore the disturbed rhythm of heart contractions by exposure to electrical discharges. The source of electrical impulses is the sinus node, which provides a uniform contraction of the myocardium, it is located in the wall of the heart. Cardioversion is subdivided into:
- Pharmacological - sinus rhythm normalizes in about fifty percent of patients when using Amiodarone, Flecainide, Propafenone and others in the treatment of paroxysmal atrial fibrillation. It gives the best result if it is started no later than forty-eight hours after the onset of the attack. In this case, there is no need for preparatory measures, in contrast to the hardware method. In addition, there is a way to normalize the heart rhythm at home. It's called the "pill in your pocket". They use "Propafenone", "Flecainide" for this.
- Electrical - this method of cardioversion is indicated for individuals with severe circulatory failure in the resulting paroxysm of atrial fibrillation.
Let's consider a case from practice. According to the medical history, paroxysmal atrial fibrillation is a preliminary diagnosis that was made to a 25-year-old patient. He made the following complaints:
- not being able to take a deep breath;
- heartbeat;
- feeling short of breath;
- general weakness;
- head spinning.
The young man was seriously engaged in powerlifting and lost consciousness during the next approach. Atrial fibrillation was diagnosed in the patient's mother and grandmother. On physical examination:
- pallor of the dermis;
- shortness of breath at rest;
- reduced pressure, the upper limit of which is 90, and the lower limit is 60 mm. rt. Art.;
- with auscultation, the heart rate is 400 beats per minute, the first tone is heard louder than normal;
- irregular rhythm on the radial artery;
- heart rate 250 beats per minute.
Additional examinations were ordered to substantiate the diagnosis.
During the period of inpatient treatment, 24-hour ECG monitoring was carried out, paroxysms of atrial fibrillation were not registered in the medical history, i.e. they were not observed. The patient underwent pharmacological cardioversion with dofetilide. As a result, sinus rhythm resumed. The young man is advised to limit physical activity.
Atrial fibrillation: treatment
Let's consider treatment options using several real case histories as an example:
- IHD, paroxysmal atrial fibrillation, heart failure - the diagnosis was made on the basis of history, examination, research. Patient N., 70 years old, was admitted to the hospital with complaints of severe compressive pain in the retrosternal region, which appears during exercise, palpitations, persistent shortness of breath and a feeling of heaviness behind the sternum. After taking Nitroglycerin, the pain syndrome was stopped after five to ten minutes. The patientIHD was diagnosed a year ago. Didn't receive any treatment. Upon admission, the dermis is pale, the borders of the heart are displaced to the left. Muffled heart sounds, tachyarrhythmia, systolic murmur, one hundred and twenty beats per minute heart rate. The following therapeutic treatment was prescribed in the he althcare facility: Anaprilin, Cordaron, Celanide, Nitroglycerin and intravenous infusion of glucose.
- Next example of a case history. IHD, paroxysmal atrial fibrillation, ventricular extrasystole, chronic heart failure. Patient T., 60 years old, on the day of arrival at a hospital, complains of such complaints as interruptions in the work of the heart (lasting for a day), appearing mainly during the day with psycho-emotional arousal and physical activity, shortness of breath, frequent heartbeat, weakness. Stops in the work of the main organ began to be felt fourteen years ago, rhythm failure according to the type of paroxysmal atrial fibrillation and ventricular extrasystole were diagnosed a month before hospitalization. After additional examinations, it was revealed: irregular and irregular sinus rhythm, sixty-six heart rate, manifestations of left ventricular hypertrophy, heart rhythm failure by the type of paroxysmal atrial fibrillation. The following treatment is listed in the medical history: bed rest, statins - Atorvastatin, anticoagulants - Clexane, then Warfarin, Aspirin cardio, Clopidogrel, Asparkam, Prestarium, Betaloc ZOK, intravenously "Sodium chloride".
- Sick K, 70 years old, was admitted tohospital with complaints of shortness of breath, fatigue, mild retrosternal pain, palpitations during exercise. He fell ill two years ago (palpitations, weakness, shortness of breath, pains in the region of the heart, radiating to the left limb and shoulder blade) suddenly appeared, the first attack occurred, during which he lost consciousness. He does not remember what treatment he received and what diagnosis was made. Upon admission, the pulse is non-rhythmic synchronous, eighty-six beats per minute. After receiving the results of additional examinations and examination data, as well as a history of the development of the disease, a clinical diagnosis was made: diffuse cardiosclerosis, coronary artery disease, atrial fibrillation. The following treatment plan is indicated in the case history: in case of repeated attacks, create conditions to ensure the flow of fresh air, seat and calm the patient. Intravenous injection of sodium chloride, Kordaron, Isoptin, Novocainamide. Use cardiac glycosides, beta-blockers.
- Sick V., 66 years old. At the time of admission, there were complaints of pressing pain in the region of the heart, which occurs during exercise. In this case, the pain gives to the lower jaw, left shoulder blade and upper limb. After taking nitrates, it stops after three minutes. When walking fast - shortness of breath. In addition, the individual notes interruptions in the functioning of the main organ, which is accompanied by a rapid heartbeat, dizziness, and general weakness. I first felt unwell six years ago. He was treated on an outpatient basis and in a hospital, took nitroglycerin, Metoprolol, Veroshpiron, acetylsalicylicacid. Preliminary diagnosis, according to the medical history: "CHD, atrial fibrillation, exertional angina". The patient was scheduled for follow-up examination. A treatment plan was formed, including the intake of nitrates, beta-blockers, calcium ion antagonists. In the absence of monotherapy with drugs from the indicated pharmacological groups, combined treatment.
Atrial fibrillation relief
For each patient with atrial fibrillation, two programs from the following are indicated in the case histories for treatment at the same time:
- For all individuals - prevention of thromboembolism. This is the primary task of physicians. For these purposes, indirect anticoagulants are used - Warfarin, Dabigatran etexilate, Rivaroxaban. In case of contraindications to their use, they are used - "Clopidogrel", "Tikagrelol", acetylsalicylic acid. In view of the fact that the use of antithrombotic therapy is dangerous due to the appearance of bleeding, their appointment to patients is decided individually, taking into account all the risks.
- In the persistent form - arrhythmia relief and relapse prevention, i.e. rhythm control. With this type of atrial fibrillation in the history of the disease, the drug of choice is Amiodarone. In addition, the clinical guidelines also include drugs such as Propafenone, Aymalin, Novocainamide, Dofetilide, Flecainide.
- With a constant form - the restoration of the heart rate. For this, preparations with a quick effect are shown - "Metoprolol" or "Esmolol", which are administered intravenously, or sublingually "Propranolol". If it is impossibleuse of pharmacotherapy or no effect, ablation is used with simultaneous implantation of a pacemaker.
- In case of paroxysmal atrial fibrillation, a treatment plan is written in the medical history to prevent new episodes of arrhythmia. For this purpose, it is recommended to regularly take antiarrhythmic drugs - Metoprolol, Bisoprolol, Propafenone, Sotalol, Amiodarone. The listed drugs have minimal side effects, including the risk of complications in the form of secondary arrhythmias.
IHD treatment
To substantiate this diagnosis, its clinical form is conclusively established. Myocardial infarction or angina pectoris are common and most typical manifestations. Other clinical signs are rarely recorded. After analyzing thousands of case histories, coronary artery disease, arrhythmic variant of atrial fibrillation met in isolated cases. This form manifests itself in the form of pulmonary edema, attacks of cardiac asthma, shortness of breath. Its diagnosis is difficult. The final diagnosis is formed based on the results of observation and data from selective coronary angiography or electrocardiographic studies in exercise tests. Specific therapy depends on the clinical form. General treatment measures include:
- Restriction of physical activity.
- Diet food.
- Pharmacotherapy - antiplatelet agents, beta-blockers, fibrates and statins, nitrates, lipid-lowering and antiarrhythmic drugs, anticoagulants, diuretics, ACE inhibitors.
- Endovascular coronary angioplasty.
- Surgery.
- Non-drug treatments - stem cells, hirudotherapy, shock wave and quantum therapy.
The prognosis of the pathology is unfavorable, since the treatment stops or slows down the process, but does not give a complete cure. The disease is chronic and progressive.
Different approaches to the treatment of permanent atrial fibrillation. Case history
In most individuals, atrial fibrillation develops into a permanent or persistent form, which aggravates the course of the underlying ailment.
In this case, the goal of normalizing sinus rhythm is basically not worth it. However, in the uncomplicated stage of the disease, physicians sometimes make attempts to normalize sinus rhythm using pharmacotherapy or cardioversion. In other cases, the goal is to achieve no more than eighty strokes at rest and one hundred and twenty under load. In addition, it is necessary to reduce the risk of thromboembolism. It is forbidden to restore sinus rhythm if, with a permanent form of atrial fibrillation, in the medical history there is information about the presence of the individual:
- heart defects requiring surgery;
- thyrotoxicosis;
- left ventricular aneurysms;
- active rheumatic diseases;
- chronic heart failure third degree;
- intracardiac thrombi;
- severe arterial hypertension;
- dilated cardiomyopathy;
- frequent bouts of arrhythmias;
- sinus node weakness and bradycardiaforms of atrial fibrillation and a decrease in heart rate.
With constant fibrillation, the effect of using medications used to restore the rhythm is within forty percent. If the illness lasts no more than two years, then the use of electrical impulse therapy increases the chance of success by ninety percent. When the failure of the rhythm lasts for a long time, and neither the doctor nor the patient makes an attempt to restore it, then the reason for this behavior is that there are doubts about maintaining sinus rhythm for a long time with diagnosed persistent atrial fibrillation.
The medical history, which is considered an important medical document, reflects the patient's condition, the scheme of diagnostic and therapeutic manipulations, and the dynamics of the disease. History is not just a listing of information received from the patient and what the doctor revealed during the examination, it is a generalized set of data presented in the form of a detailed and logically coherent report. The quality of this document is directly dependent on the level of knowledge of the doctor. In addition, during its execution, special rules should be followed, the observance of which will help to avoid various errors, including legal ones. For example, when the main diagnosis is "CHD, atrial fibrillation, a permanent form", the case history indicates in great detail and in detail: complaints, anamnesis of the disease and life, data from an objective and additional examination, treatment plan. In the case of a permanent variant of arrhythmia, surgical treatment is indicated -ablation and installation of a special device (pacemaker). After surgery, the prognosis for the life of the individual is favorable.
Clinical pharmacology history: atrial fibrillation
The story describes in detail the following anamnesis of the individual: life, hereditary, expert labor, pharmacological, allergological. As well as the data of an objective examination, the results of instrumental and laboratory methods of research, the rationale for the differential and clinical diagnosis, the purpose and objectives of treatment. A reasonable choice of pharmacological groups is carried out to cure a particular patient. For example, the most important directions in the treatment of atrial fibrillation are getting rid of the arrhythmia directly and preventing thromboembolic consequences. There are two ways to treat atrial fibrillation:
- Restoration and maintenance of sinus rhythm - cardioversion (pharmacological and electrical). With it, there is always a risk of thromboembolism.
- Ventricular rate control while maintaining atrial fibrillation. Stabilization of sinus rhythm is mandatory for persistent atrial fibrillation. In the case histories of different patients, both electrical and pharmacological cardioversion are encountered. In addition, the preservation of sinus rhythm is also necessary in individuals with paroxysmal atrial fibrillation. The predominantly used medicines for this purpose are Disopyramide, Propafenone, Procainamide, Amiodarone.
When choosing a drug from one group, excludeddrugs that can worsen the patient's condition. They describe in the case history both the interaction of the selected drugs, and the negative phenomena that may appear during pharmacotherapy. The following describes the effectiveness of the treatment.
