1. RACHEL KITCHEN Atrial Fibrillation

2. Overview Definition and epidemiology Symptoms Tests/Evaluations Complications Treatment Effects on exercise Medications effect on exercise Effects of training Exercise prescription

3. Definition Rapid unorganized electrical impulses (not coming from the sinus node-thus not sinus rhythm) cause the atria to squeeze in a rapid and unorganized manner. This is called fibrillation. Often referred to as a-fib Most common type of arrhythmia Affects millions of people Men are more likely to have than women Risk increases as you age Uncommon in children

4. Definition Paroxysmal atrial fibrillation  Begins suddenly and stops on its own. Usually stops and starts whithin 24 hours to a week. Persistent atrial fibrillation  May start and stop on its own or with treatment. Usually lasts more than a week. Permanent atrial fibrillation  Atrial fibrillation persists and the normal heart rhythm cannot be brought back with treatment.

5. Normal Sinus Rhythm vs. Atrial Fibrillation

6. Doctors involved Primary care doctor (family practitioners and internists Cardiologist Electrophysiologist (Cardiologist who specializes in arrhythmias)

7. Signs and Symptoms Palpitations/Irregular beats/Skipped beats Shortness of breath Weakness or problems exercising Chest pain Fatigue Confusion

8. Risk Factors High blood pressure Coronary heart disease (CHD) Heart failure Rheumatic heart disease Mitral valve prolapse Pericarditis Congenital heart defects Sick sinus syndrome Post heart attack or surgery Obesity Diabetes Drinking large amounts of alcohol

9. Laboratory Diagnosis Ambulatory telemetry monitor (ATM) (1-30 day monitoring at home)  Patient presses a symptoms button when having symptoms  If asymptomatic, monitor will catch any abnormalities. If atrial fibrillation is found or other serious arrhythmia the doctor will be notified  This is a newer and very effective way to diagnose and catch atrial fibrillation Holter monitor (24 hours monitoring at home) EKG (10 second strip) Stress tests Echocardiography Transesophageal Echocariography (TEE) Chest X-ray Blood tests

10. Tests Methods MeasuresEndpointsComments Aerobic Cycle Treadmill ( ind. ramp protocol, 8- 12 min target. Moderately incremented protocol<1MET/2- 3 min (naughton/balke) *12-lead ECG, HR *BP *RPE *Angina scale *Gas analysis (VO2 peak) *Radionuclide *testing *Serious dysrhythmias *>2mm ST- segment dep/elev *ischemic threshold *T- wave inversion with st change *SBP > 250 mmhg or DBP >115 mmhg *3+ on angina scale Better estimate of exercise capacity Endurance 6 min walk Distance walkedRest stops allowed Flexibility Goniometry Angle of flexion/extension If lowered ROM

11. Complications Two major complications /Heart failure and stroke Heart failure  Heart can’t pump blood sufficiently to the body. The ventricles are pumping really fast to get the blood to the body, but because they don’t completely fill with blood, they may not be able to get enough blood to the lungs and body  Black legs  Fatigue and SOB are common symptoms. Buildup of fluid in the lungs, feet, ankles, and legs causing weight gain. Important to weigh patient. If gaining lots of weight ask if they are retaining fluid

12. Complications Stroke  Because atria may not be pumping all the blood out. It can pool and form clots. If the atria pumps a clot through, it can travel to the brain and cause a stoke  Some individuals who are asymptomatic with atrial fibrillation will have a stroke first then be diagnosed late

13. Atrial fibrillation can cause stroke http://www.youtube.com/user/boeh ringeringelheim?v=eb1nLeQiWOM

14. Treatment: Medical and Surgical Medicines  Blood clot prevention: Coumadin, heparin, warfarin(84% reduction in stroke risk), and aspirin (aspirin is less effective than warfarin)  Rate control: Beta blockers(metoprolol and atenolol) calcium channel blockers(diltiazem and verapamil) and digitalis (digoxin)  Rhythm control: Amiodarone, sotalol, flecainide, propafenone, dofetilide, and ibutilide. Electrical cardioversion  http://heart.emedtv.com/electrical-cardioversion-video/what- happens-during-electrical-cardioversion-video.html

15. Treatment: Medical and Surgical Catheter ablation:  Wire is inserted through a vein in the arm or leg up to the heart. Radio wave energy is sent through to destroy bad tissue that is disrupting the normal electrical flow  Sometime they will destroy the AV node and put in a pacemaker. The pacemaker will help to maintain a normal rhythm Maze surgery:  Requires open heart surgery. They make small cuts or burns in the atria. This helps to prevent the spread of disorganized or disobedient electrical signals

16. Effects of Disease on Ability to Exercise Insufficient scientific literature is available about exercise training and atrial fibrillation They would not have a significantly different response than a normal sinus rhythm individual. However, the medication they are on will have an influence on exercise The major concern is underlying problems like heart disease, valvular disease, heart failure, and CAD These underlying conditions should be the most important in considering exercise training

17. Effects of Medications on Ability to Exercise Digoxin  May control ventricular response; diffuse ST effects Calcium channel blockers  May mask ischemia and decrease exercise heart rate response Diltiazem, verapamil  Help control ventricular response; may improve exercise capacity Beta blockers  Help control ventricular response; may reduce exercise capacity. Decrease submaximal and maximal HR and BP response; sometimes exercise capacity, especially with nonselective medications Things to consider  Age-predicted max HR targets ARE NOT VALID  Irregular ventricular response may make BP values less precise or more difficult to get

18. Exercise Programming ModesGoalsIntensity/Freque ncy, Duration Time to goal Aerobic *Large muscles activities *Arm/leg ergometry *Increase VO2 peak *Increase ADLs *RPE 11-16/20 *50-80% VO2 peak or HR reserve *3-7 days/week *30-45 min/session 3 Months Resistance Weight machinesIncrease strength*High reps, low resistance (12- 15reps) *2-3 nonconsecutive days/week 2-3 Months Flexibility Upper and lower body ROM activities *Increased felxibility *Reduce risk of injury 3-5 days/week2-4 Months

19. Summary Atrial fibrillation is most common type of arrhythmia Can cause stroke or heart failure Some can be treated for atrial fibrillation others can live with it Individuals who have atrial fibrillation can exercise, focus on underlying conditions Medications can have effect on assessment during exercise

20. References ACSM. 2010. ACSM’s guidelines for exercise testing and prescription, 8 th ed. Baltimore: Lippincott Williams and Wilkens, chapter 5. American Heart Association. 2010. Cardiovacular Statistics. http:/.www.american heart,org/ Durstine, J. L et al., editors. Exercise management for persons with chronis diseases and disabilities. Champaign, IL: Chapter 9. National Heart Lung and Blood Institute. (2001). What is atrial fibrillation? http://nhlbi.nih.gov/health/health-topics/topics/af/http://nhlbi.nih.gov/health/health-topics/topics/af/ Youtube video on atrial fibrillation and stroke: http://www.youtube.com/user/boehringeringelheim?v=eb1nLeQi WOM http://www.youtube.com/user/boehringeringelheim?v=eb1nLeQi WOM Youtube video on electrical cardioversion: http://heart.emedtv.com/electrical-cardioversion-video/what- happens-during-electrical-cardioversion-video.html

21. Questions