Atrial fibrillation etiology and differential diagnosis
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| Conduction | ||
Sinus rhythm  | Atrial fibrillation  | |
| Atrial fibrillation Classification and external resources | |
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|---|---|
| The P waves, which represent depolarization of the atria, are irregular or absent during atrial fibrillation. | |
| ICD-10 | I48. |
| ICD-9 | 427.31 |
| DiseasesDB | 1065 |
| MedlinePlus | 000184 |
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 Discuss Atrial fibrillation etiology and differential diagnosis further in the WikiDoc Cardiology Network |
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Synonyms and related keywords: AF, Afib, fib
Etiology of atrial fibrillation
AF can be associated with underlying cardiac diseases, but it may also occur in otherwise normal hearts.
Common Causes
Complete Differential Diagnosis of Underlying Etiologies for Atrial Fibrillation
| Cardiovascular | Acute myocardial infarction • Congenital heart disease especially atrial septal defect in adults • Coronary artery disease • Heart failure (especially diastolic dysfunction and diastolic heart failure) • Hypertrophic cardiomyopathy (HCM) • Hypertension • Mitral regurgitation
Mitral stenosis (e.g. due to Rheumatic heart disease or Mitral valve prolapse) • Myocarditis • Pericarditis • Previous heart surgery • Dual-chamber pacemakers in the presence of normal atrioventricular conduction.[1] • Restrictive cardiomyopathies (such as amyloidosis, hemochromatosis, and endomyocardial fibrosis), cardiac tumors, and constrictive pericarditis |
| Congenital | |
| Dermatologic | No underlying causes |
| Drugs | Digoxin in patients with vagally mediated AF |
| Ear Nose Throat | No underlying causes |
| Endocrine | Hyperthyroidism • Hypothyroidism • Pheochromocytoma |
| Gastroenterologic | Vomiting |
| Genetic | A family history of AF increases risk by 30%.[2] Various genetic mutations may be responsible.[3] |
| Hematologic | No underlying causes |
| Infectious Disease | No underlying causes |
| Musculoskeletal / Ortho | No underlying causes |
| Neurologic | Multiple sclerosis |
| Nutritional / Metabolic | No underlying causes |
| Oncologic | No underlying causes |
| Opthalmologic | No underlying causes |
| Overdose / Toxicity | Excessive alcohol consumption ("binge drinking" or "holiday heart syndrome") • Carbon monoxide poisoning • Caffeine • Stimulants |
| Post-Op Complication | Surgery,particularly coronary artery bypass surgery • During pulmonary artery line placement and right heart catheterization trauma to the right atrium can result in atrial fibrillation |
| Pulmonary | Hypoxia of any cause • Lung cancer • Pneumonia • Pulmonary embolism • Sarcoidosis • sleep apnea syndrome |
| Renal / Electrolyte | Hypokalemia |
| Rheum / Immune / Allergy | No underlying causes |
| Trauma | Electrocution • Cardiac contusion |
| Miscellaneous | Hypothermia • Fever |
The autonomic nervous system may trigger AF in susceptible patients through heightened vagal or adrenergic tone
Morphology
The primary pathologic change seen in atrial fibrillation is the progressive fibrosis of the atria. This fibrosis is primarily due to atrial dilatation, however genetic causes and inflammation may have a cause in some individuals.
Dilatation of the atria can be due to almost any structural abnormality of the heart that can cause a rise in the intra-cardiac pressures. This includes valvular heart disease (such as mitral stenosis, mitral regurgitation, and tricuspid regurgitation), hypertension, and congestive heart failure. Any inflammatory state that affects the heart can cause fibrosis of the atria. This is typically due to sarcoidosis but may also be due to autoimmune disorders that create autoantibodies against myosin heavy chains. Mutation of the lamin AC gene is also associated with fibrosis of the atria that can lead to atrial fibrillation.
Once dilatation of the atria has occurred, this begins a chain of events that leads to the activation of the renin aldosterone angiotensin system (RAAS) and subsequent increase in matrix metaloproteinases and disintegrin, which leads to atrial remodeling and fibrosis, with loss of atrial muscle mass.
This process is not immediate, and experimental studies have revealed patchy atrial fibrosis may precede the occurrence of atrial fibrillation and may progress with prolonged durations of atrial fibrillation.
Fibrosis is not limited to the muscle mass of the atria, and may occur in the sinus node (SA node) and atrioventricular node (AV node), correlating with sick sinus syndrome. Prolonged episodes of atrial fibrillation have been shown to correlate with prolongation of the sinus node recovery time,[4] [5][6] suggesting that dysfunction of the SA node is progressive with prolonged episodes of atrial fibrillation.
Signs and symptoms
In general, clinical manifestations are;
- Palpitations
- Chest pain
- Dyspnea
- Fatigue
- Lightheadedness
- Syncope: Syncope is an uncommon but serious complication that is usually associated with sinus node dysfunction or hemodynamic obstruction, such as valvular aortic stenosis, HCM, cerebrovascular disease, or an accessory AV pathway.
Atrial fibrillation is usually accompanied by symptoms related to the rapid heart rate. Rapid and irregular heart rates may be perceived as palpitations, exercise intolerance, and occasionally produce angina (if the rate is faster and puts the heart under strain) and congestive symptoms of shortness of breath or edema. Sometimes the arrhythmia will be identified only with the onset of a stroke or a transient ischemic attack (TIA, stroke symptoms resolving within 24 hours). It is not uncommon to identify atrial fibrillation on a routine physical examination or electrocardiogram (ECG/EKG), as it may be asymptomatic in many cases.[4]
As most cases of atrial fibrillation are secondary to other medical problems, the presence of chest pain or angina, symptoms of hyperthyroidism (an overactive thyroid gland) such as weight loss and diarrhea, and symptoms suggestive of lung disease would indicate an underlying cause. A previous history of stroke or TIA, as well as hypertension (high blood pressure), diabetes, heart failure and rheumatic fever, may indicate whether someone with atrial fibrillation is at a higher risk of complications.[4]
See Also
References
- ↑ Sweeney MO, Bank AJ, Nsah E, et al (2007). "Minimizing ventricular pacing to reduce atrial fibrillation in sinus-node disease". N. Engl. J. Med. 357 (10): 1000-8. doi:10.1056/NEJMoa071880. PMID 17804844.
- ↑ Fox CS, Parise H, D'Agostino RB, et al (2004). "Parental atrial fibrillation as a risk factor for atrial fibrillation in offspring". JAMA 291 (23): 2851-5. doi:10.1001/jama.291.23.2851. PMID 15199036.
- ↑ Saffitz JE (2006). "Connexins, conduction, and atrial fibrillation". N. Engl. J. Med. 354 (25): 2712-4. doi:10.1056/NEJMe068088. PMID 16790707.
- ↑ Cite error 8; No text given.
- ↑ Elvan A, Wylie K, Zipes D (1996). "Pacing-induced chronic atrial fibrillation impairs sinus node function in dogs. Electrophysiological remodeling". Circulation 94 (11): 2953–60. PMID 8941126.
- ↑ Manios EG, Kanoupakis EM, Mavrakis HE, Kallergis EM, Dermitzaki DN, Vardas PE (2001). "Sinus pacemaker function after cardioversion of chronic atrial fibrillation: is sinus node remodeling related with recurrence?". Journal of Cardiovascular Electrophysiology 12 (7): 800–6. doi:10.1046/j.1540-8167.2001.00800.x. PMID 11469431.
Further Readings
- Fuster V, Rydén LE, Cannom DS, et al (2006). "ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation 114 (7): e257-354. doi:10.1161/CIRCULATIONAHA.106.177292. PMID 16908781.
- Estes NAM 3rd, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS, McNamara RL, Messer JV, Ritchie JL, Romeo SJW, Waldo AL, Wyse DG. ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with non valvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Performance Measures for Atrial Fibrillation). Circulation 2008; 117:1101–1120
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Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
