Acute Atrial Fibrillation

A review of the management of *acute* atrial fibrillation, including relevant pharmacology, indications for cardioversion, and anticoagulation.
#afib #atrialfibrillation #cardiology

[sunving]

Thank you Dr Strong, for taking time of your busy schedule to make this educational video.

[MedSurvival_Med_Mnemonics]

It is mandatory to address the cause of atrial fibrillation prior to rate/rhythm control. Like Treat Anxiety, Pain, Anemia, Electrolytes like K/Mg, Respiratory problem, Infection etc.

[zanyarqadir]

Very new and practical ED infos, thanks dr

[zuhairyassin]

medicine outside medschool is a totally different beast god help us all

[thedudeabides]

Fantastic. I rarely use diltiazem because I was told it is also contraindicated in structural heart disease and often the patient with fast AF has had no recent echo

[epilepsyawarenessaidresear]

Amazing and very informative. Thank you 😊

[keithharrison]

My own experience may be of interest, where I am fairly certain I had an external physical cause for a three month period of otherwise inexplicable Atrial Fibrillation (lasting up to 9 days at a time).

(1) I had sleep problems, with repetitive nightmares associated with imagined chattering teeth (I was in fact suffocating, due to undiagnosed Sleep Apnoea).

(2) One night I went into Atrial Flutter, and attended Hospital where this was diagnosed via ECG, and reversed via IV Fluids, Magnesium and a Beta Blocker, namely 5mg Bisoprolol Fumarate. Nobody then realised it was due to Sleep Apnoea, but I worked that out almost the next day.

(3) I was put onto a daily precautionary dose of 5mg Bisoprolol Fumarate, which mainly seemed to cause Bradycardia, especially at night, so I halved that to 2.5 mg to reduce the Bradycardia, and later to 1.25 mg for the same reasons. I had various other tests, and my heart was found to be healthy with no structural issues.

(4) I was eventually diagnosed with Severe Sleep Apnoea, and prescribed CPAP (Constant Positive Airway Pressure). I also have pretty severe Osteoarthritis in all lower joints from past injury, so cannot stop myself rolling on to my back, where I get the most relief from pain, but that is the worst position for Sleep Apnoea. For that reason, I find I need to run my CPAP Machine at the maximum pressure of 20 cm H20, which I find is fine, and stops most Apnoeas, but I struggle to stop my Face Mask from leaking air at that pressure.

(5) I tried various CPAP Masks, and settled on the Prescribed ResMed F20. I have to keep the straps tight to stop leaks, but I can usually stop all leaks now.

(6) Over the following 2 years, I experienced random irregular heart beats, which seemed to be Ectopic Beats or Premature Atrial Contractions (my own ECGs show an normal Lead I waveform, with what seems to be a premature malformed P wave, then normal QRS, then a normal T Wave, then a delayed P/QRS/T and then back to normal. This seemed to be linked to food as well, so I have to avoid anything with bad fats, such as Trans Fats or Palm Oil. That has to be some Vagal Gastro Cardiac link, but it happens 15 minutes after consuming such food (usually by accident until we work out what was in the food).

(7) I had two acute Atrial Fibrillation sessions and had to return to Hospital, but both subsided without any intervention. I continued to struggle with night time Bradycardia due to the Beta Blocker, that I kept at 1.25 mg.

(8) Early this year, I went into regular episodes of Atrial Fibrillation (mix of Brady and inappropriate Tachy), and despite a Hospital Visit that confirmed this, the only suggested help was to vary the dose of the Beta Blocker. That seemed to make things worse, and the Bradycardia became a real problem.

(9) I felt that something was driving this, and my own small ECG was mainly showing a weird mixture of Bradycardia and inappropriate Tachycardia, as if my electrical system was misfiring, and unable to settle on a beat.

(10) Trying to find a solution, I tried various things, including trying to stimulate a Vagus Reaction, such as thrusting my face into cold water, and also massaging the Vagus nerves either side of my neck. Bingo! The latter had an effect, and I noted my heart rate changed, and seemed to be linked to my Vagus nerves.

(11) Then it all made sense. The tight Straps on my CPAP Mask, went right across my Vagus Nerves either side of my neck, just below my ears. This was always painful, and left deep welt marks by the morning. I felt that was a possible cause, as the Vagus Nerve is part of the body's parasympathetic system, so there is a link with heart rate control.

(12) That day, I fabricated a Foam Neck pad from my wife's Yoga Mat, so 8mm open cell foam. This covered the back of my head, and also extended below my ears and onto my face, and was around 70mm wide over my Vagus Nerves to spread the Strap loading.

(13) That worked, the Atrial Fibrillation stopped same night, and has not returned after some four Months. Also, the odd PACs died away, although I had many just afterwards, these reduced in frequency the longer I wore the neck pad.

(14) I have since modified the design, and added plastic panels above the Foam where it goes over the Vagus Nerves, to further spread the Strap load. I also no longer have any neck pain, nor any marks on my face by the morning.

(15) I do not in effect now have Sleep Apnoea, because the CPAP is stopping the effects. So I had no evidence of any Sleep Apnoea triggering the Atrial Fibrillation, there were no signs of one impacting the other. So normal sleep, no Oxygen Drops, but random unrelated Atrial Fibrillation that seemed via my ECG to be a mixture of slow and fast beats.

In summary

Tight CPAP Mark Straps could be a cause of Atrial Fibrillation in some people.

If Sleep Apnoea is diagnosed, and the patient is using CPAP at higher pressures, and has a CPAP Mask where narrow Straps go over the Vagus Nerve area in the neck, then any otherwise inexplicable Atrial Fibrillation may need to be investigated in terms of the CPAP Equipment.

Sadly, I could not interest the local Cardiologist to consider this as a cause. I asked for help for the 3-4 Months this was happening, but did not even get a call for nearly 6 months, when he simply dismissed this explanation without looking at my many ECGs and well considered research!

The fact is, the problem went away the very day I took steps to protect my Vagus Nerves. Unless I have missed something, I just cannot see that this is not the true cause in my case.

I also stopped the Beta Blocker, which took some doing, and no longer now suffer from Bradycardia, and I also feel like a medicinal cosh has been lifted. I did try to point out the Bradycardia issues, and that the Beta Blocker may not be needed but, that too fell on deaf ears. As I understand it, a Beta Block is contraindicated in cases of Vagal Atrial Fibrillation.

There is a cardiac link, as there are documented cases of premature babies being placed onto CPAP, and suffering Atrial Fibrillation until their CPAP Mask and Straps are adjusted, so as not to interfere with their Vagus Nerves in their necks. There are other documented cases where Vagus Nerve damage after, say, accident, has led to Atrial Fibrillation issues.

I am not selling anything, and have nothing to gain from setting the above out. I am simply relaying my own experience in case this may help others.

[aryazand]

This video is very timely for this intern. Thank you!

[andynightingale]

Many thanks for this. Very interesting as an occasional acute Afib patient. Flecanide IV seems to revert my rhythm back usually. Hate the condition though, detest the symptoms.

[MedSurvival_Med_Mnemonics]

Always look for other causes of instability among patients with AF and shock or difficulty controlling the ventricular rate.

[rajeevpr]

Great video.Thank you Sir.I have stated clicking the like symbol even before watching them.

[olgaszabo]

Hi I favorite your videos and I would like to ask you if it possible: Could you share an video low rate A-Fib? Thank you so much.

[teresabridgart]

I wish you had added some dosing regime for use of IV procainamide. This drug is only recently available here (and hard to get) and finding a consistent dosing protocol, and being familiar with it, is difficult.
Otherwise, great video :)

[kizzable]

Brilliant thank you, needed for this 1st year med student 🤗

[rekhakadam]

Sooo well explained!!! Many thanks 🙏🏻 please do a video on diabetes... treatment... how to proceed!!!

[dailydoseofmedicinee]

Certain situations can trigger an episode of atrial fibrillation, including:

drinking excessive amounts of alcohol, particularly binge drinking.

being overweight (read about how to lose weight)

drinking lots of caffeine, such as tea, coffee or energy drinks.

taking illegal drugs, particularly amphetamines or cocaine.

👍

[ryancohenmusic]

Some of my patients who are diagnosed with afib and on anticoagulation appear to be in afib or irregular at times - yet asymptomatic. Is this emergent?

[ΆγιοςΧίλαριος]

I have one question: when the patient for instance presenting with afib with ventricular response ~ 150 bpm, sBP ~ 70 mmHg & known to have HFrEF with EF~ 25, RV is involved, & enlarged left atrium, , I'm not sure of cardioversion might be successful in restoring sinus rhythm (with risk of embolism) & even if SR was restored, , mechanical LA contraction might not occur only after hours-days ... Wouldn't rate control be superior to cardioversion? (Digoxin might benefit but with ↑sympathetic tone is less likely to be effective & AKI is very common in such a case.. I'm thinking of amio + vasopressor [I know this might ↑VR] ) ..

[DrAmrinderSinghKangar]

Dear Dr Strong, I have a doubt regarding cardioversion. If a patient has AF with RVR with Shock, do we really have the time to do transesophageal echo? What should be our immediate strategy here? THANKS.

[Jackie]

Hi i had an at home sleep study and have mild sleep apnea but had a BPM go as high as 129 is this afib?