CLINICAL SIGNS:
* irregular heartbeat more or less fast between 60 and 160 / min with variable amplitudes, permanent or paroxysmal.
* no functional signs.
* or asthenia and moderate dyspnea.
* or palpitations or oppressions unpleasant, paroxysmal.
* or inaugural lipolysis or even syncope type Adams-Stokes.
* look for signs of valvulopathy (especially mitral) on auscultation.
* complications :
Functional or organic angina in relation to the underlying cardiac disease.
– cerebral arterial embolism.
– cardiac decompensation, OAP, collapse.
– convulsions, confusional state in the elderly person.
ETIOLOGY:
* mitral stenosis .
* Hypertrophic, dilated or obstructive cardiomyopathy.
* arterial hypertension.
* ischemic cardiomyopathy.
* hyperthyroidism.
* acute alcoholic intoxication.
* chronic respiratory failure.
* hypokalemia, hypo-hypercalcemia.
* atrial disease, WPW.
iatrogenic: digitalis, theophylline.
* idiopathic (20%).
DIAGNOSTIC TESTS:
* scope.
* ECG :
– absence of P wave.
– waves f (400 to 600 / mn): anarchic tremulations of the baseline, clearly visible in V1.
– The QRS complexes are fine (except in case of pre-existing block or conduction aberration), not equidistant.
* Blood ionogram , CPK, ASAT, LDH, TSH .
* chest x-ray.
* in a second time:
– holter ECG and echocardiography: volume of the atrium, thrombus, search for valvulopathies.
TREATMENT:
* Medicated if recent fibrillation or if old but poorly tolerated or complicated:
– venous route, possibly oxygen therapy to the mask.
– correct any hypokalemia.
– Digoxine Nativelle : 1 to 2 IV ampoules slow per day then ½ to 1 ampoule per day if f> 80 / min except if WPW, hypokalemia, polymorphic ESV, myocardial excitability, digitalis.
– or Cordarone (reduced better than Digoxine Nativelle, to prefer if underlying angina):
– loading dose: 30 mg / kg per os (or 1 cp / 10 kg), half-dose the next day.
– or route IV: 2 ampoules (300 mg) in infusion of 30 minutes then 600-1200 mg / d with the electric syringe.
– after TSH assay.
– sometimes in relay of the digoxin if failure of this one after 3 hours.
– effective anticoagulation before the attempt of reduction:
– Heparin:
IV bolus of 50 IU / kg.
– then 400 to 600 IU / kg / day to the electric syringe
– or LMWH in curative doses.
– reduction by electric shock under general anesthesia if failure of the drug treatment, in a second time.
* if old fibrillation and well tolerated:
– Digoxin: ½ to 1 cp per day depending on age +/- betablocker.
– preventive anticoagulation (Sintrom, Préviscan, Apegmone) unless contraindicated (give then Aspegic 250).
