ATRIAL

FIBRILLATION

L AT I FA H H U S N A Z U L K A F L I
C 111 11 871
SUPERVISOR:
P R O F D R . P E T E R K A B O,
PHD, SP FK, SP JP (K) ,
F I H A , FA S C C

CASE REPORT
A woman, 58 years old come to hospital with chest thumping. This condition
felt intermittent, since 1 year ago, and become heavier for the last 2 days
before entering the hospital. This thumping become worst if she do the
strenuous activity. Shortness of breath doesnt exist, but she had the history
of shortness breath. Orthopnoea doesnt exist, Paroxymal Nocturnal Dyspnoea
(PND) doesnt exist. Chest pain denied. The history of chest pain doesnt exist.
History of diseases:
History of Hypertension since 15 years ago, with no regular treatment.
History of another heart diseases denied.
History of smoking and alcoholism denied.

PHYSICAL
EXAMINATION
General Examination:
BP: 160/100 mmHg
HR: 84x/ minutes, irregular
RR: 20x/ minutes
T: 36,5C

Heart Examination:
Symetrical chest
Heart pulsation (-)
Percussion:
Upper boundary: ICS II Linea parasternalis sinistra
Right boundary: ICS IV Linea parasternalis dextra
ICS V Linea mid axillary sinistra

Head & Neck in normal limits:

JVP: R+1 cmH2O

SI / SII irregular, additional sound (-)

ELECTROCARDIOGRAM
(ECG)
Rythm : Supraventrikular
rhythm, irregular
Heart Rate
Axis

: 85

: +300 (Normoaxis)

P Wave
assess

: difficult to

PR Interval
assess

:difficult to

QRS complex : 0,08 seconds

ST Segment

: no elevation

T Wave
: T inverted on
V3-V6 lead

Atrial Fibrillation,Normal Ventrikular Response

(HR 85x/minutes), Normoaxis.

LAB. RESULT
Test

Result

Normal
value

Normal

Test

Result

Ureum

13

10-50

Kreatinin

0,77

0,5-1,2

value

7.0 x

4.0 10.0 x

10 /uL

103

4.49 x

4.0 6.0 x

106/uL

106

HGB

14.1 g/dL

12 16

Troponin T

<0.01

<0,01

HCT

42%

37 48

CK

81.00

<190

271x

150 400 x

103/uL

103

CKMB

18.5

<25

<140

Na

146

136-145

WBC

RBC

PLT

GDS

128
mg/dL

SGOT

20

<38

3,4

3,5-5,1

SGPT

15

<41

CL

114

97-111

Cardio-Thoracal Index: 63%

DIAGNOSE
& TREATMENT
Diagnose:
Atrial Fibrillation woth Normal
Ventricular Response
Hypertension Grade II

Treatment:
Bed rest
IVFD NaCl 0,9 % 500 cc/24 jam
Amlodipine 10mg/24jam/oral
Irbesartan 300mg/24jam/oral
Bisoprolol 2.5mg/24jam/oral
Simarc 2mg/24jam/oral

ATRIAL
FIBRILLATION

DEFINITION
Atrial Fibrillation (AF) is the process of Supraventrucular Tachiarythmia, with
uncoordinated of atrium activation. This process can make the atrial
mechanism being more worst. Perhimpunan Dokter Spesialis Kardiovaskkular
Indonesia, 2014

An irregular and often rapid heart rate, commonlycausespoor blood flow to

the body. The heart's two upper chambers (theatria) beat chaotically and
irregularly out of coordination with the two lower chambers (the ventricles) of
the heart. Europian Heart Jurnal, 2010

RISK FACTOR

EPIDEMIOLOGY
Estimates of AF in Asia through
2014 suggest that 12,210,000
(0.4%) people in the AsiaPacific have atrial fibrillation.
AF is most prevalent in South
Korea, Philippines, Malaysia
and Indonesia, affecting 0.7%
of the populations.
Hypertension is the most
common CV risk factor across
the Asia.

ETIOLOGY
CARDIAC
Ischemic heart disease
Rheumatic Heart Disease
Hypertension

NON CARDIAC
Acute infection especially pneumonia
Electrolyte depletion
Lung carcinoma

Cardiomyopathy or heart
muscle disease
Pericardial disease
Atrial septal defect

Pulmonary embolism
Thyrotoxicosis

HEART
ANATOMY
Size; 12cm, 8-9cm wide, 6cm
thickness, &weight 7 15
ons.
Wall heart structure;
Epicardium, Myocardium,
Endocardium
Conduction system; start
from small pacemaker bundle
of cells Sinoatrial (SA) node
conductive tissue
Atrioventricular (AV) node
Purkinje fibers.

HEART
PHYSIOLOGY
Systole; cardiac muscle
tissue is contracting to push
blood out of the chamber.
Diastole; the cardiac muscle
cells relax to allow the
chamber to fill with blood.
Cardiac Cycle
- Atrial Systole; the atria
contract and push blood into
the ventricles.
- Ventricular Systole; the
ventricles contract to push
blood into the aorta and
pulmonary trunk opened
semilunar closed AV valves.
- Relaxation Phase; all 4
chambers of the heart are in

PATHOPHYSIOLOGY
The atria and ventricles no longer
beat in a coordinated way. This
creates a fast and irregular heart
rhythm. In AF, the ventricles may
beat 100 to 175 times a minute, in
contrast to the normal rate of 60
to 100 beats a minute.

CLINICAL
MANIFESTATION

CLASSIFICATION
Depend on time and the
duration:
AF 1st diagnose
AF Paroxymal; spontaneous
termination in 48hours,
&disappearing before 7 days
AF Persistent; until 7days or AF
that need cardioversion with
drugs or electricity.
AF Long Standing Persistent;
staying for 1 year
AF Permanent

CLASSIFICATION
Depend on episodic duration:
AF Lone; AF without cardiovascular
diseases (HT, Pulmonary disease,
LAE, & age under 60)
AF Non-Valvular; AF without valvular
diseases (mitral rheumatic disease,
etc)
AF Secondary; cause of another
primary condition (myocardial
infarction, pericarditis,
hyperthyroidism, pneumonia)

Depend on ventricle respond (RR Interval):

Rapid ventricle respond; >100x / minutes
Normal ventricle respond; 60 100x /minutes
Slow ventricle respond; <60x/ minutes

 Iregular heart rate

(110-140x/minutes),
deficit pulse.
Exopthalmus,hipethyr
oidsm, increasing of
JVP or sianotic. Bruit
in carotic artery.
Heart Failure; ronchi,
pleural
efussion),
wheezing (COPD
AF)
S3 sounds; ventricle
enlargement
&
increased
left
ventricle pressure
Sianotic

LABORATORIUM

>50%
asymptomatic
(silent atrial
fibrillation)
Palpitaion
Easy to feeling tired
Presyncope or
Syncope
Dizziness
Clasificate the AF
Risk factor (activity,
alcoholism)
Drugs;
AntiArythmia
Comorbid diseases
(HT, CHD, DM,
Hyperthyroidsm,
COPD)

PHYSICAL EXAMINATION

ANAMNESIS

HOW TO DIAGNOSE?
Complete blood
count
Electrolyte,
ureum, creatinin
Heart enzyme;
CKMB and or
Troponin (Myocard
Infark AF)
Natriuretic
Peptide, in AF
patient
D-Dimer lung
embolism
Thyroid function

By walking 6
minutes test,
it can helping
us to find the
AF
was
triggered
by
activity or not
(normal,
HR
<110x/
minutes after
6
minutes
walking)

RADIOLOGY

Unvisible P wave,
displaced by
irregular F wave
and irregular QRS
complex
Heart Rate; 110140x/ minutes
Ashman
Phenomenon;
widened QRS
complex after R-R
short-long interval
Pre excitation
Left ventricle
hyperthrophy
The sign of old
infark

WALKING EXAMINATION

ELECTROCARDIOGRAM (EKG)

HOW TO DIAGNOSE?
CT scan or
MRI; evaluate
the atrium
anatomy
Holter Monitor;
for Paroxymal
AF,
Electrophysiolo
gy; identificate
tachycardia
mechanism

ELECTROCARDIOGRAM
(EKG)

MANAGEMENT
Reduce
thromboemb
olic risk

Restore and
maintain
sinus rhythm
(Rhythm
control)

Therape
utic
goals in
patient
with AF

Control
ventricle rate
during AF
(Rate
control)

ANTITROMBOTIC
Used for preventing stroke;
Anticoagulant; Warfarin (25mg orally or
intravenously) or Coumadin
Antiplatelet; Aspirin (75150mg orally) or
Clopidogrel (75mg per day)

RATE
CONTROL
Beta blockers(preferably the
"cardioselective" beta
blockers such
asmetoprolol,atenolol,bisopr
olol,nebivolol)
Non-dihydropyridinecalcium
channel
blockers(e.g.,diltiazemor
verapamil)
Digitalis(e.g.,digoxin)

RHYTM
CONTROL
Cardioversionis the attempt to
switch an irregular heartbeat
normal heartbeat
Electrical cardioversioninvolves
the restoration of normal heart
rhythm through the application of
a DC electrical shock
Chemical cardioversionis
performed with drugs:
Amiodarone, Dofetilide,
Flecainide, Ibutilide, Propafenone,
Quinidine

SURGERY
Catheter Ablation
At the end of the catheter contain
electode which terminates ectopic
focus.
Maze procedure
an effective invasive surgical
treatment that is designed to
create electrical blocks or barriers
in the atria of the heart, forcing
electrical impulses that stimulate
the heartbeat to travel down to the
ventricles.
Artificial pacemaker

PREVENTION
Reduce risk by changing some
behaviors(life style)
Cutting down intake of alcohol.
Stop smoking and using nicotine
products, and avoid over-the-counter
medications that have stimulant
properties.
Make sure any health conditions are
being properly treated.
Work to reduce stress and maintain a
healthy weight.

PROGNOSIS
Treatment can often control this disorder. Many people with atrial
fibrillation do very well.
Atrial fibrillation tends to return and get worse. It may come back
even with treatment.
Clots that break off and travel to the brain can cause astroke.

THANK YOU