Atrial fibrillation: medical history, clinical recommendations

In medical practice, there are situations when an individual’s heart beats quite often, and the reason for this phenomenon is not in a stressful situation, but this is a constant type of atrial fibrillation. In the medical 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. Moreover, every year more and more such patients are registered. This is due to an increase in life expectancy, including of elderly individuals with such a diagnosis.

Atrial flutter and atrial fibrillation: what is the difference?

A heart rhythm failure in which muscle fibers contract chaotically and at a tremendous frequency, reaching up to six hundred beats per minute, is called atrial fibrillation. Outwardly, such a process is manifested by a frequent pulse, but it is very difficult to feel it. It seems that it is flickering. Thanks to such an unusual comparison, the disease received a second name - atrial fibrillation.

Flutter is considered a milder variation in arrhythmia. In this case, up to four hundred beats per minute reaches the heart rate, 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 malfunctions are different, which is necessarily reflected in the medical records. Atrial fibrillation is an irregular contraction of heart muscle cells at unequal intervals, as well as the presence of several foci that are in the left atrium and send extraordinary abnormal discharges. Flutter is carried out at regular intervals due to the agreed muscle contraction, since the impulses come from only one focus.

Classification of Atrial Fibrillation

Consider the systematization used by practicing doctors. Atrial fibrillation is divided into:

• First identified - diagnosed at the moment, and there is no further mention of its detection. This type is asymptomatic and with severe symptoms, paroxysmal or permanent.
• Persistent - fibrillation lasts more than a week. To differentiate in practice this and paroxysmal form is quite difficult.
• Persistent for a long time, or it is also called stable, worries the patient for a year or more. A pronounced clinical picture is observed only during physical exertion.
• The paroxysmal form of atrial fibrillation in the history of the disease indicates its sudden appearance and self-disappearance within two days. If the seizures last up to seven days, then they are also referred to this form of the disease. The patient feels periodic malfunctions in the heart, which are accompanied by weakness, pressure drops, shortness of breath, dizziness and chest pain. In rare cases, a fainting state occurs.
• A long persisting affliction is constant atrial fibrillation. The medical history reflects the mutual decision (of the doctor and the patient) that no attempts will be made to restore the normal sinus rhythm. With the consent of the individual, that is, when he changes his mind, measures are taken to control the rhythm. In this case, arrhythmia again becomes a prolonged persistent.

Clinical classification or due to occurrence. According to such a systematization, atrial fibrillation is distinguished by concomitant diseases or conditions that increase the risk of arrhythmia. Consider the types of fibrillations:

1. Secondary - heart disease acts as provocateurs.
2. Focal - characteristic of young patients, especially in the presence of atrial tachycardia in the past or short-term cases of fibrillation.
3. Polygenic - formed against the background of multiple gene mutations at a fairly early age.
4. Monogenic - occurs with a single gene mutation.
5. Postoperative - open heart surgery is a provocateur.
6. In professional athletes, it occurs with paroxysms and depends on intense and long trainings.
7. In patients with valve anomaly, it is formed after surgery to correct the valve apparatus, as well as with mitral stenosis.

By severity. EAPC scale, it is used to assess the quality of life:

• 1 - symptoms of the disease are absent.
• 2a - minor manifestations, there is no threat to the individual.
• 2b - palpitations and shortness of breath are felt, but the ability to perform daily work is not lost.
• 3 - pronounced signs of arrhythmia: weakness, palpitations, shortness of breath.
• 4 - the ability to serve oneself is lost.

Prevalence. Genetic aspects

As the analysis of medical records, or rather, case histories, shows, ischemic heart disease and tachysystolic form of atrial fibrillation occurs in individuals from twenty years old and older, that is, about 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;
• increase in life expectancy.

In addition, it was found that the danger of getting sick is higher in men, but the fair sex is more susceptible to women, as they have many associated pathologies and a pronounced clinical picture of heart rhythm failure.

It is proved that the gene mutation is the basis of the disease, i.e., the individual, even in the absence of associated cardiovascular risks, is at great risk of atrial fibrillation. Doctors know about fourteen variants of changes in the genotype that lead to rhythm failure.

Diagnostics

Before making a diagnosis of atrial fibrillation, the doctor makes a medical history in the history of the disease, where the following information will be important information:

• the presence of anomalies of the thyroid gland, gastrointestinal tract, lungs and others;
• whether there were similar rhythm disturbances in close relatives;
• in women - manifestations of menopause;
• if the patient himself noticed a rhythm disturbance, then the doctor will be interested in how much they last.

Next, a physical examination is performed. With his help, the doctor also conducts differential diagnosis with flutter. When listening, the heart rate will vary from the heart rate on the wrist. The conclusion about the regularity of the rhythm is made on the basis of the ECG, which is considered a particularly informative method of diagnosis. All information received is also recorded in the medical history. When examining elderly individuals, an electrocardiogram is necessarily shown. Such a 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.

Currently, there are innovative methods by which individuals can independently identify violations. However, they are inferior to a cardiogram in terms of informativeness.

Therapeutic measures

After diagnosis of atrial fibrillation, a comprehensive treatment is performed. This takes into account factors such as:

• symptoms
• blood pressure numbers;
• heart rate;
• the risk of cerebrovascular accident;
• the likelihood of sinus rhythm recovery;
• the presence of concomitant pathology, exacerbating the course of arrhythmia.

After assessing the condition of the patient, the doctor decides on the tactics of his conduct.

For the prevention of stroke are shown:

• Warfarin
• “Dabigatran”, “Apixaban”.

The following strategies are used to control the frequency of heartbeats:

• heart rate control;
• resumption of natural sinus rhythm.

Of course, the choice of tactics for the treatment of atrial fibrillation depends on a number of reasons - this is the experience of the pathology, 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 everyday life improves.

The drugs of choice for rapidly reducing heart rate are Verapamil, Diltiazem, and Bisoprolol. When arrhythmias are combined with heart failure, combinations of beta-blockers with digitalis derivatives, Digoxin, are indicated. For individuals with unstable pressure, the introduction of Amiodarone intravenously is recommended.

For continuous use:

• Beta-blockers - Carvedilol, Metoprolol, Nebivolol. Regardless of age, they are well tolerated.
• "Digoxin". It is important to choose the right dosage due to toxicity.
• The reserve medicine is Amiodarone.

Thus, in a disease - atrial fibrillation - in order 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.

In practice, it has been proven that percutaneous catheter ablation is effective in treating atrial fibrillation, and especially in reducing symptoms. Using this method together with the latest anticoagulants and antiarrhythmic drugs of a new generation significantly improve the prognosis. Treatment of atrial fibrillation is:

• taking anticoagulants;
• correction of cardiovascular pathology;
• symptom relief.

According to the latest clinical recommendations, the treatment of atrial fibrillation is based on new approaches to antiarrhythmic therapy. To reduce the incidence of atrial fibrillation or to 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 electric discharges. The source of electrical impulses is the sinus node, which provides uniform contraction of the myocardium, it is located in the wall of the heart. Cardioversion is divided into:

1. Pharmacological - sinus rhythm is normalized in about fifty percent of patients 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, unlike the hardware method. In addition, there is a way to normalize the heart rhythm at home. It has received the name "tablet in a pocket". Use for this "Propafenone", "Flecainide."
2. Electrical - this method of cardioversion is indicated for individuals with pronounced circulatory failures with the resulting paroxysm of atrial fibrillation.

Consider a case from practice. According to the medical history, the paroxysmal form of atrial fibrillation is a preliminary diagnosis, which was made to a patient 25 years old. He made the following complaints:

• inability to breathe fully;
• palpitations
• feeling of lack of air;
• general weakness;
• dizziness.

The young man was seriously engaged in powerlifting and lost consciousness at the next approach. Atrial fibrillation was diagnosed in the patient’s mother and grandmother. With an objective examination:

• pallor of the dermis;
• dyspnea at rest;
• reduced pressure, the upper boundary of which is 90, and the lower - 60 mm. Hg. st .;
• with auscultation, the heart rate is 400 beats per minute, the first tone is heard louder than the norm;
• irregular rhythm on the radial artery;
• pulse of 250 beats per minute.

To substantiate the diagnosis, additional examinations were prescribed.

During inpatient treatment, 24-hour ECG monitoring was performed; paroxysms of atrial fibrillation were not recorded in the medical history, i.e., they were not observed. The patient underwent pharmacological cardioversion "Dofetilide." As a result, the sinus rhythm resumed. It is recommended that a young person limit physical activity.

Atrial fibrillation: treatment

Consider the treatment options as an example of several real case histories:

1. IHD, paroxysmal atrial fibrillation, heart failure - the diagnosis was made on the basis of anamnesis, examination, and research. Patient N., 70 years old, was admitted to the hospital with complaints of severe compressive pain in the sternum, which appears during exercise, palpitations, persistent shortness of breath, and a feeling of heaviness behind the sternum. After taking Nitroglycerin, the pain stopped after five to ten minutes. The patient was diagnosed with IHD a year ago. I did not receive any treatment. Upon receipt, the dermis is pale, the borders of the heart are shifted to the left. Muffled heart sounds, tachyarrhythmia, systolic murmur, one hundred twenty beats per minute, heart rate. The following therapeutic treatment was prescribed at a health care facility: Anaprilin, Cordaron, Celanide, Nitroglycerin, and intravenous glucose infusion.
2. The following is an example of a medical history. IHD, paroxysmal atrial fibrillation, ventricular extrasystole, chronic heart failure. Patient T., 60 years old, on the day of arrival at the inpatient facility presents such complaints as interruptions in the work of the heart (lasting for a day), which appear mainly during the day with psycho-emotional excitement and physical activity, shortness of breath, frequent heartbeat, weakness. He began to feel stops in the work of the main organ fourteen years ago, a rhythm failure by the type of paroxysmal form of 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 according to the type of paroxysmal atrial fibrillation. The following treatment is listed in the medical history: bed rest, statins - “Atorvastatin”, anticoagulants - “Kleksan”, then “Warfarin”, “Aspirin cardio”, “Clopidogrel”, “Asparkam”, “Prestarium”, “Betalok ZOK”, intravenously "Sodium chloride".
3. Patient K, 70 years old, was admitted to the hospital with complaints of shortness of breath, fatigue, mild chest pain, frequent palpitations during physical exertion. He fell ill two years ago (suddenly there was a heartbeat, weakness, shortness of breath, pain in the region of the heart, radiating to the left limb and shoulder blade), the first attack occurred, during which he lost consciousness. He did not remember what treatment he received and what was the diagnosis. Upon receipt, the pulse is non-rhythmic synchronous, eighty-six beats per minute. After obtaining the results of additional examinations and examination data, as well as the history of the disease, a clinical diagnosis was made: diffuse cardiosclerosis, coronary heart disease, atrial fibrillation. The following treatment plan is indicated in the history of the disease: in repeated attacks, create conditions to ensure an influx of fresh air, to seat and reassure the patient. Introduce sodium chloride, Cordaron, Isoptin, Novocainamide intravenously. Use cardiac glycosides, beta-blockers.
   
4. Patient V., 66 years old. At the time of admission, there were complaints of pressure pain in the region of the heart that occurs during exercise. In this case, the pain radiates 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 rapid heartbeat, dizziness, and general weakness. I first felt unwell six years ago. He was treated on an outpatient basis and in the hospital, took nitroglycerin, Metoprolol, Veroshpiron, acetylsalicylic acid. A preliminary diagnosis, according to the medical history: "IHD, atrial fibrillation, exertional angina." The patient is assigned an additional examination. A treatment plan has been formed, including the intake of nitrates, beta-blockers, calcium ion antagonists. In the absence of monotherapy with medicines from the indicated pharmacological groups, a combined treatment.

Relieving atrial fibrillation

In each patient with atrial fibrillation, two programs from the following are indicated simultaneously for treatment in the case histories:

• For all individuals - the 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 use Clopidogrel, Ticagrelol, acetylsalicylic acid. Due to the fact that the use of antithrombotic therapy is dangerous by the appearance of bleeding, their appointment to patients is decided individually, taking into account all the risks.
• With a persistent form - the arrest of arrhythmias and the prevention of relapses, i.e., rhythm control. In this type of atrial fibrillation in the medical history, the drug of choice is Amiodarone. In addition, in clinical recommendations, such drugs as Propafenone, Aimalin, Novocainamide, Dofetilide, Flecainide are also indicated.
• With a constant form - the restoration of the frequency of heart contractions. For this, preparations with a quick effect are shown - “Metoprolol” or “Esmolol”, which are administered intravenously, or sublingually “Propranolol”. If pharmacotherapy cannot be used or if there is no effect, ablation is used with simultaneous implantation of a pacemaker.
• With paroxysmal atrial fibrillation, a treatment plan is written in the history of the disease to prevent new episodes of arrhythmia. For this purpose, regular intake of antiarrhythmic drugs is recommended - Metoprolol, Bisoprolol, Propafenone, Sotalol, Amiodarone. The listed drugs have minimal side effects, including the risk of complications in the form of secondary arrhythmia.

IHD treatment

To substantiate this diagnosis, its clinical form is conclusively established. Myocardial infarction or angina pectoris is a common and most common manifestation. Other clinical signs are rarely recorded. Having analyzed thousands of case histories, coronary heart disease, an arrhythmic variant of atrial fibrillation was found in isolated cases. This form manifests itself in the form of pulmonary edema, attacks of cardiac asthma, shortness of breath. Her diagnosis is difficult. The final diagnosis is formed according to the results of observation and data from selective coronary angiography or electrocardiographic studies in samples with a load. The specific therapy depends on the clinical form. Common therapeutic measures include:

• Restriction of physical activity.
• Dietary nutrition.
• Pharmacotherapy - antiplatelet agents, beta-blockers, fibrates and statins, nitrates, lipid-lowering and antiarrhythmic drugs, anticoagulants, diuretics, ACE inhibitors.
• Endovascular coronary angioplasty.
• Surgical intervention.
• Non-drug methods of treatment - stem cells, hirudotherapy, shock wave and quantum therapy.

The prognosis of the pathology is unfavorable, since treatment stops or slows down the process, but does not provide a complete cure. The disease is chronic and progressive.

Different approaches to the treatment of persistent atrial fibrillation. Medical history

In most individuals, atrial fibrillation goes into a constant or persistent form, which exacerbates the course of the underlying ailment.

In this case, the goal of normalizing sinus rhythm is basically not worth it. However, with an unburdened stage of the disease, doctors sometimes make attempts to normalize the sinus rhythm using pharmacotherapy or cardioversion. In other cases, the task is to achieve no more than eighty shocks at rest and one hundred and twenty at load. In addition, it is necessary to reduce the risk of thromboembolism. It is forbidden to restore the sinus rhythm, if with a constant form of atrial fibrillation in the medical history there is information about the presence of the individual:

• heart defects requiring surgical intervention;
• thyrotoxicosis;
• aneurysms of the left ventricle;
• rheumatic diseases in the active stage;
• chronic heart failure of the third degree;
• intracardiac thrombi;
• severe arterial hypertension;
• dilated cardiomyopathy;
• frequent attacks of arrhythmia;
• weakness of the sinus node and bradycardic form of atrial fibrillation and a decrease in heart rate.

With constant fibrillation, the effect of the use of medicines used to restore rhythm is within forty percent. If the disease lasts no more than two years, then the use of electropulse therapy increases the chance of success by ninety percent. When a rhythm failure lasts a long time and neither the doctor nor the patient makes attempts to restore it, the reason for this behavior is that there are doubts about maintaining a sinus rhythm for a long time with diagnosed constant atrial fibrillation.

The medical history, which is considered an important medical document, reflects the patient’s condition, the scheme of diagnostic and therapeutic procedures, and the dynamics of the disease. History is not just a listing of the information received from the patient, and what the doctor revealed during the examination, it is a generalized data set presented in the form of a detailed and logically coherent report. The quality of the design of this document depends on the level of knowledge of the doctor. In addition, when designing it, you should adhere to special rules, the observance of which will help to avoid various errors, including legal ones. For example, with the main diagnosis, "IHD, atrial fibrillation is a constant form," the medical history shows in great detail and 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 an individual's life is favorable.

Clinical Pharmacology Case History: Atrial Fibrillation

In history, the following anamnesis of an individual is described in detail: life, hereditary, expert labor, pharmacological, allergological. As well as data from 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 treating atrial fibrillation are getting rid of arrhythmia directly and preventing thromboembolic consequences. There are two ways to treat atrial fibrillation:

• Recovery and retention of sinus rhythm - cardioversion (pharmacological and electrical). When carrying out it, there is always a risk of thromboembolism.
• Ventricular rhythm control while maintaining atrial fibrillation. Stabilization of the sinus rhythm is necessary with a persistent form of atrial fibrillation. In the case histories of different patients, both electrical and pharmacological cardioversion is found. In addition, the preservation of sinus rhythm is necessary in individuals with a paroxysmal form of atrial fibrillation. The predominantly used medicines for this purpose are Dizopyramide, Propafenone, Procainamide, Amiodarone.

When choosing a drug from one group, medicines that can aggravate the patient's condition are excluded. They describe in the medical history and the interaction of the selected drugs, and the negative phenomena that may appear during pharmacotherapy. The following describes the effectiveness of the treatment.