Chapter 21

• Irregularly irregular rhythm.
• Absence of P waves on the electrocardiogram.

Atrial fibrillation, the most common sustained clinical arrhythmia, is diagnosed by finding an irregularly irregular ventricular rhythm without discrete P waves (Figure 21–1). The QRS complex is usually narrow, but it may be wide if aberrant conduction or bundle branch block is present. Atrial fibrillation associated with the Wolff-Parkinson-White syndrome may occur with very rapid ventricular rates and may be life-threatening. This arrhythmia is diagnosed by its very rapid irregular rate associated with wide preexcited QRS complexes and requires emergency treatment (see Long-Term Approach).

Figure 21–1.

The 12-lead electrocardiogram shows the typical rapid irregular rhythm seen with atrial fibrillation.

Approximately 4% of the population over age 60 years has sustained an episode of atrial fibrillation, with a particularly steep increase in prevalence after the seventh decade of life. Risk factors for development of atrial fibrillation include heart failure, hypertensive cardiovascular disease, coronary artery disease, and valvular heart disease. Moreover, both sustained and paroxysmal atrial fibrillation have important implications for the development of a cerebrovascular accident (CVA) or other systemic emboli. It is estimated that 15–20% of CVAs in nonrheumatic patients are due to atrial fibrillation.

Symptoms and Signs

When called on to manage new-onset atrial fibrillation, it is important to establish the precipitating factors because the type of associated condition determines long-term prognosis. In some patients, episodes of atrial fibrillation may be initiated by caffeine, alcohol, or marijuana use. Atrial fibrillation may result from acute intercurrent ailments. For example, this arrhythmia may develop in patients with hyperthyroidism or lung disease, or after either cardiac or pulmonary surgery, especially in older patients. Atrial fibrillation is also seen in patients with acute pulmonary embolism, myocarditis, or acute myocardial infarction, particularly when the last condition is complicated by either occlusion of the right coronary artery or heart failure. When atrial fibrillation occurs in these settings, it almost always abates spontaneously if the patient recovers from the underlying problem. Hence, management usually involves administration of drugs to control the heart rate, and long-term antiarrhythmic therapy is generally not needed.

Alternatively, atrial fibrillation may occur in association with structural cardiac disease. Important associated conditions include rheumatic mitral stenosis, hypertension, hypertrophic cardiomyopathy, or chronic heart failure. In contrast to patients with acute intercurrent ailments, those with structural heart disease may expect (even with antiarrhythmic therapy) many recurrences and chronic atrial fibrillation may supervene.

Lone fibrillation is the term used to describe patients with atrial fibrillation not associated with known cardiac conditions or noncardiac precipitants. The natural history of the atrial fibrillation for those with lone atrial fibrillation is similar to that in patients with structural cardiac disease, in that episodes of atrial fibrillation are likely to recur and, eventually, the arrhythmia may become sustained.

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