1. UCLA Family Medicine Department IMG Program Carlos Yoo

2. A 66 year-old man comes to the emergency department complaining of a several-day history of an intermittent sensation of fluttering in the chest. He feels weak when the episodes occur but denies chest pain or shortness of breath. He has had hypertension for 20 years, controlled well with enalapril, and he takes albuterol for asthma. He denies any alcohol use. UCLA Family Medicine Department IMG Program Carlos Yoo

3. VS: Temperature 36.8C (98.3F), Blood pressure 140/80, pulse 140/min, respirations 12/min PE: supple neck, no jugular vein distension or thyromegaly. CV: irregularly irregular rhythm with no rubs or gallops. Chest: clear sounds Abd: Benign Extremities: no edema UCLA Family Medicine Department IMG Program Carlos Yoo

4. Atrial Fibrillation Multifocal atrial tachycardia Supraventricular tachycardia Pulmonary Embolism Thyrotoxicosis UCLA Family Medicine Department IMG Program Carlos Yoo

5. EKG Thyroid Function tests Cardiac enzymes Echocardiogram ABGA UCLA Family Medicine Department IMG Program Carlos Yoo Within Normal limits Normal Within Normal limits Normal Ejection fraction, left atrial enlargement

6. Elderly patient Palpitation Fatigue/weakness Long term hypertension Tachycardia Irregularly irregular rhythm EKG: atrial fibrillation waves, inconsistent R-R intervals, absence P waves. UCLA Family Medicine Department IMG Program Carlos Yoo ATRIAL FIBRILLATION

7. GOALS Hemodynamic stabilization Ventricular rate control Prevention of embolic complication UCLA Family Medicine Department IMG Program Carlos Yoo

8. Patient with diagnosis of atrial fibrillation Hemodynamically stable Control ventricular rate: Diltiazem Cardioversion YesNo Spontaneous conversion to sinus rhythm Assess cause of atrial fibrillation YesNo Contraindication to cardioversion? Cont Beta Blockers Calcium Channel blockers Digoxin Amiodarone Unstable… Hypotension Confusion Angina …. Long standing HTN Ischemic heart dz CHF Hyperthyroidism PE Lung ca Alcohol Hypothermia Electrolytes imbalance Etc.. Long standing HTN Ischemic heart dz CHF Hyperthyroidism PE Lung ca Alcohol Hypothermia Electrolytes imbalance Etc..

9. UCLA Family Medicine Department IMG Program Carlos Yoo Consider long-term anticoagulation Cardiversion YesNo >48hs<48hs Start Heparin IV Immediate medical or electrical cardioversion Later elective cardioversion after 3weeks of warfarin Early TEE- guided cardioversion Atrial fibrillation persist? Assess cause of atrial fibrillation Yes No Cont Long standing HTN Ischemic heart dz CHF Hyperthyroidism PE Lung ca Alcohol Hypothermia Electrolytes imbalance Etc.. Long standing HTN Ischemic heart dz CHF Hyperthyroidism PE Lung ca Alcohol Hypothermia Electrolytes imbalance Etc.. WarfarinAspirin

10. http://www.chestjournal.org/content/13 5/3/849.full.html http://www.aafp.org/afp/20020715/249. html http://www.aafp.org/afp/20020715/261. html http://www.americanheart.org/downloa dable/heart/222_ja20017993p_1.pdf UCLA Family Medicine Department IMG Program Carlos Yoo