CARDIOLOGY CASEBOOK
A regular feature of the American Journal of Critical Care, Cardiology Casebook is intended to enhance practi-
tioners’ knowledge and critical thinking. Stylized case studies are accompanied by self-assessment quizzes. We
welcome letters to the editors regarding this feature.
A. FIB.
By Laurie G. Futterman, ARNP, MSN, CCRN, and Louis Lemberg, MD. From the Division of Cardiology,
Department of Medicine, University of Miami School of Medicine, Miami, Fla.
A 76-year-old retired, decorated police officer
consulted his family physician because of
palpitations 1 day in duration. He had been
feeling well and physically active doing household
chores and yard work: he was not taking any medica-
tions. Although uncomfortable because of the palpita-
tions; he was not dyspneic and had no chest pains. On
physical examination, his blood pressure was 130/75
mm Hg in the right arm, and the lungs were clear on
auscultation. The point of maximal cardiac impulse was
in the 5th intercostal space at the midclavicular line.
The ventricular rate was 98 beats/min and very irreg-
ular. An electrocardiogram (ECG) confirmed the
physician’s impression of a diagnosis of atrial fibrilla-
tion (AF). There were no acute repolarization changes
(ST-T) and no abnormal Q waves. The jugular venous
pulses were not elevated and there was no hepato-
jugular reflux, thus eliminating the possibility of con-
gestive heart failure. The patient was reassured that
the arrhythmia could be managed and he would be
able to return to full activity.
QUESTIONS
1. The treatment of AF has included which of the
following?
a. measures to control the heart rate
b. measures to restore sinus rhythm
c. anticoagulation to prevent
thromboembolism
d. the “MAZE procedure”
e. ablation of atrial foci at the insertion
of the pulmonary veins
f. any of the above in addition to “c.”
2. Historically the aim in managing AF was which
of the following?
Request for reprints: Louis Lemberg, MD, University of Miami School of
Medicine, Division of Cardiology (D-39), P.O. Box 016960, Miami, FL 33101.
438 AMERICAN JOURNAL OF CRITICAL CARE, September 2005, Volume 14, No. 5
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a. rate control
b. rhythm control
c. anticoagulation
3. Rate control therapeutic measures in AF
include which of the following?
a. drugs that block atrioventricular (AV)
nodal transmission
b. ablation of the AV node
c. pacemaker implantation
d. anticoagulation
e. all of the above
ANSWERS
1. f. any of the above in addition to “c.”
Atrial fibrillation is a chaotic atrial rhythm with an
atrial rate so fast (350-600 discharges/min) that it
makes it difficult to discern P waves on an ECG (Fig-
ure 1). Many atrial impulses encounter refractory tis-
sue at the AV node, and as a result only some of the
depolarizations are conducted to the ventricle in a very
irregular rhythm. Atrial fibrillation, the most common
sustained arrhythmia is found in 0.5% of the general
population, affects over 2 million patients in the United
States, and is more prevalent in males.1,2 The incidence
of AF is approximately 1% in patients under 60 years
of age and over 8% in those more than 80 years of
age.3 Seventy percent of patients with AF are 65 to 80
years of age. The increased prevalence of AF in the
elderly may be the result of the longer life span cur-
rently experienced in patients with chronic diseases.
AF is associated with cardiac diseases (eg, hyperten-
sive heart disease, rheumatic mitral stenosis, coronary
artery disease, congestive heart failure) and noncardiac
diseases (eg, hyperthyroidism, hypoxic pulmonary
lesions, surgery, alcohol intoxication, sleep apnea, and
obesity). There is a 5-fold increased risk of stroke and
a 2-fold increase in mortality in patients with AF, even
after adjustments are made for preexisting cardiovascu-
 Figure 1 Rhythm trace showing changing fibrillatory waveforms characteristic of atrial fibrillation.
lar diseases.2,4 Lone AF is a diagnosis in patients less
than 60 years of age who have no evidence of other
cardiovascular diseases, hypertension, or diabetes.
Echocardiography can confirm the lack of structural
heart disease. In lone AF, the risk of stroke is low and
anticoagulation for stroke prevention is considered
unnecessary; nevertheless, low-dose aspirin is still used
because epidemiologically aspirin lessens the risk of
stroke and acute myocardial infarction (MI) in patients
with lone AF. The incidence of stroke in patients with
lone AF is low; nevertheless, the occurrence of a cere-
bral vascular accident can be devastating.5
The treatment of AF has gone through many
changes in the past 30 years. These have varied from
therapy aimed at rate control to treatment controlling
rhythm; however, anticoagulation was never an option. In
the “MAZE procedure,” multiple surgical incisions are
made in the left and right atria to create barriers to
stop atrial propagation of reentrant waves.6 The result is
a more directed atrial impulse. Recently catheter ablation
of rapid atrial foci localized near the insertion of the pul-
monary veins has been effective at suppression of AF.
Successful catheter ablation of the AV node causing AV
block requires implantation of a permanent pacemaker to
ensure an adequate ventricular rate. Recent reports in
the Atrial Fibrillation Follow-up Investigation of Rhythm
Management Trial (AFFIRM) revealed that stable
patients with AF had similar survival rates and had no
difference in quality of life whether on rhythm or rate
control therapy.7 Other trials report that hospitalization
rates and costs are lower with rate control rather than
with rhythm control. Important to note is that AF occur-
ring postoperatively or following an acute MI can often
be rapidly converted to sinus rhythm with β-blocker ther-
apy. Early use of β-blockers at the onset of an acute MI
and prior to extensive surgery in populations that have an
increased potential for AF developing will often pre-
vent the occurrence of AF (L.L., personal observation).
Short-term daily use of low-molecular-weight heparin
and aspirin is relatively safe in cases of postoperative
AF, which is usually transient following surgery.
AMERICAN JOURNAL OF CRITICAL CARE, September 2005, Volume 14, No. 5
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2. b. rhythm control
c. anticoagulation
Pharmacological conversion therapy aimed at
rhythm control (reestablishing sinus rhythm) has been
achieved with any of the following agents: ibutilide,
flecainide, dofetilide, propafenone, or amiodarone;
moderate efficacy has been observed with quinidine
therapy. The chief drawbacks in antiarrhythmic drug
therapy are the adverse reactions to these drugs and
the potential hazards of torsades de pointes that can
occur in the presence of a prolonged QT interval. Tor-
sades de pointes translates to “twisting of the points”
and is a polymorphic ventricular tachycardia present-
ing as varying amplitudes of the QRS as if the com-
plexes are “twisting” about the baseline. The dangers
of torsades de pointes are syncope and ventricular fib-
rillation (Figure 2).
Maintenance of normal sinus rhythm after electri-
cal or pharmacological conversion from AF is diffi-
cult: recurrence rates are high, 75% in untreated and
50% in treated patients.8 Rates of recurrence are par-
ticularly high in those 65 years of age and older, the
segment of the population with the highest incidence
of AF. Continued pharmacotherapy is often required to
prevent recurrence of AF. Initiation of antiarrhythmic
therapy with agents such as amiodarone, sotalol, dofet-
ilide, disopyramide, and propafenone carries risks of
proarrhythmia and sudden cardiac death and usually
requires hospitalization and close follow-up. The risks
are even greater in those with structural heart disease.
Anticoagulation therapy is routine in AF regardless of
the treatment mode.
3. e. all of the above
Treatment of persistent AF aimed at rate control
is clinically simple and less hazardous than therapy
for rhythm control. Atenolol, metoprolol, diltiazem,
and verapamil have been used with varying degrees of
effectiveness in the control of the ventricular response
rate in AF. Rate control can be achieved with the com-
bined use of digoxin, and a β-blocker titrated to a tar-
439
 Figure 2 Characteristic electrocardiographic strip of torsades de pointes, a descriptive term indicating 180° changes in QRS axis
often initiated by a ventricular premature beat that falls within a prolonged QT interval.
geted ventricular response rate appropriate at rest and
during moderate exercise, for example, walking 30
yards at a brisk pace (L.L., personal observation).
Age, the physical state, and the clinical state influence
the optimal resting and exercise ventricular response
rate in AF. Rate control is appropriate when the ven-
tricular response with moderate exertion is not excessive.
As a general rule, with normal left ventricular function,
a resting heart rate of 60 to 70 beats/min and rates of 80
to 90 beats/min with moderate exertion are appropriate.
AV nodal blockade may often lead to secondary
bradycardia and subsequent pacemaker implantation for
rate support. Hemodynamically significant breakthrough
rapid ventricular rates, or the occurrence of disabling
symptoms despite adequate AV nodal blocking agents,
may require AV node ablation. Following AV node
ablation, implantation of a permanent pacemaker (rate
responsive VVI or DDD) is required to provide physi-
ological rate support. As with any therapeutic regimen
in AF, anticoagulation is standard therapy.
Summary
AF is the most commonly sustained clinical arrhyth-
mia, with an incidence that increases 2-fold with every
decade after 55 years of age. There is an estimated
prevalence of about 2 million Americans with AF. AF
is the most frequent principal diagnosis of cardiac
arrhythmias, responsible for approximately 265 000
hospital admissions annually.7 These statistics make
managing AF a major issue. The therapeutic goal in the
past was to restore and maintain sinus rhythm. Car-
dioversion was successful and often used; however,
maintaining sinus rhythm following conversion required
the use of antiarrhythmic drugs that were potentially
proarrhythmic. The AFFIRM trial proved that rhythm
control of AF has no mortality benefits over rate con-
trol therapy.7 In fact, in elderly patients, rhythm con-
trol was associated with a higher mortality than rate
control.9 The quality of life substudy of the AFFIRM
trial revealed no differences in the quality of life
between the rate- and rhythm-controlled patients.
Current therapy recommends that patients with
AF can be successfully managed and will experience
440 AMERICAN JOURNAL OF CRITICAL CARE, September 2005, Volume 14, No. 5
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an equal quality of life when treated to control the
heart rate or to maintain a sinus rhythm following
conversion of AF. However, rate control especially in
the elderly is preferable.
ACKNOWLEDGMENT
Supported in part by a grant from the Applebaum Foundation in loving memory of
Joseph Applebaum.
REFERENCES
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2. de Denus S, Sanoski CA, Carlsson J, et al. Rate vs rhythm control in
patients with atrial fibrillation. Arch Intern Med. 2005;165:258-262.
3. Snow V, Weiss KB, LeFevre M, et al. Management of newly detected
atrial fibrillation: a clinical practice guideline from the American Academy
of Family Physicians and the American College of Physicians. Ann Intern
Med. 2003;139:1009-1017.
4. Wasmund Sl, Li JM, Page RL, et al. Effect of atrial fibrillation and an
irregular ventricular response on sympathetic nerve activity in human sub-
jects. Circulation. 2003;107:2011-2015.
5. Engel TR, Topalian SK. The pathology of lone atrial fibrillation. Chest.
2005;127:424-425.
6. Futterman LG, Lemberg L. An alternative to pharmacologic management of
atrial fibrillation: the MAZE procedure. Am J Crit Care. 1994;3:238-242.
7. The AFFIRM Investigators. Quality of life in atrial fibrillation: The atrial
fibrillation follow-up investigation of rhythm management (AFFIRM)
study. Am Heart J. 2005;149:112-120.
8. Saxonhouse SJ, Curtis AB. Risks and benefits of rate control versus main-
tenance of sinus rhythm. Am J Cardiol. 2003;91(6A):27D-32D.
9. Vidaillet HJ. Rate control vs. rhythm control in the management of atrial
fibrillation in elderly patients. Am J Geriatr Cardiol. 2005;14:73-78.
SELECTED REFERENCES
Conti CR. Stroke and atrial fibrillation: to anticoagulate or not. Clin Cardiol.
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Marshall DA, Levy AR, Vidaillet H, et al. Cost-effectiveness of rhythm versus
rate control in atrial fibrillation. Ann Intern Med. 2004;141:653-661.
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Opolski G, Torbicki A, Kosior D, et al. Rhythm control versus rate control in
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Singh BN, Singh SN, Reda DJ, et al. Amiodarone versus sotalol for atrial fib-
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Wyse DG. Rhythm versus rate control trials in atrial fibrillation. J Cardiovasc
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Atrial Fibrillation
Laurie G. Futterman and Louis Lemberg
Am J Crit Care 2005;14 438-440
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