Black Birds

Frozen Time

One of the first shots with my new camera.

Atrial fibrillation

Hockey is my winter sport. As a hockey fan I’ve recognized something this season other than the new NHL rules, but several players have had episodes of atrial fibrillation (a fib). Atrial fibrillation is a relatively common arrhythmia (irregular heart beat). The incidence of a fib is highest among elderly and those with structural heart disease. It is a rare condition in healthy young adults and children. The overall incidence of a fib was 1 percent. Seventy percent of that 1 percent were over 65 years old. It was slightly more common in men that woman, and whites than blacks.

Etiology:
A fib is almost always associated with structural heart disease of any nature. This heart disease is almost always associated with heart failure, atrial enlargement, and increased atrial pressure. One study was performed with a 24 hour heart monitor called a Holter monitor. It was found that patient’s with structurally normal heart that underwent paroxysmal a fib, the trigger was premature atrial contractions.

Other diseases associated with atrial fibrillation can be summed up in the pneumonic PASMITH:
• P- pulmonary etiology such as pulmonary embolism or pulmonary infection.
• A- Alcohol
• S- sleep apnea and COPD
• M- mitral valve disorder from rheumatic heart disease
• I- infraction (coronary artery disease and acute coronary syndrome), inflammation (i.e. pericarditis)
• T- Thyroid disorder (i.e. hyperthyroidism)
• H- hypertensive heart disease, heart failure, hypertrophy of the left ventricle.

Other conditions to consider: post coronary artery bypass surgery, medications such as theophylline or adenosine, and obesity.

Signs and Symptoms:
There are no specific signs of symptoms of a fib. Many patients are asymptomatic. Typical symptoms include palpitations, a sense of the heart racing, fatigue, lightheadedness, increased urination, or mild shortness of breath. More severe symptoms and signs include dyspnea, angina, hypotension, presyncope, or infrequently syncope (Uptodate.com)

Diagnosis:
• Blood work to check electrolytes, thyroid function,
• EKG,
• chest x ray,
• Holter monitoring,
• possible exercise stress testing.

Indications of hospitalization:
Any patient with a new onset a fib to rule out a myocardial infarction is my recommendation. Other factors to consider include:
• For the treatment of an associated medical problem, which is often the reason for the arrhythmia
• For elderly patients who are more safely treated for AF in hospital
• For patients with underlying heart disease who have hemodynamic consequences from the AF or who are at risk for a complication resulting from therapy of the arrhythmia (Uptodate.com)

Treatment: there are 4 approaches to treatment

1. Rhythm control- conversion to normal sinus rhythm
2. Rate control
3. Choosing between rate or rhythm control
4. Need for anticoagulation

As a student I have always had difficulty with the decision between rate control and rhythm control. From my research this is how I practice now. There was a study produced comparing the efficacy of the two options (the trials were AFFIRM and RACE). There were two conclusions.
1. Embolic events occur with equal frequency regardless of whether a rate control or rhythm control strategy is pursued, and occur most often after warfarin has been stopped or when the International Normalized Ratio (INR) is subtherapeutic (Uptodate.com)
2. Both studies showed an almost significant trend toward a lower incidence of the primary end point with rate control (hazard ratio 0.87 for mortality in AFFIRM and 0.73 for a composite end point in RACE) (show figure 8 and show figure 9). There was no difference in functional status or quality of life (Uptodate.com)

Based on these guidelines one concludes the following. First, you should attempt rate control. If the patient continues to have persistent severe symptoms (i.e. palpitations, dyspnea, lightheadedness, angina, presyncope, and heart failure), inability to control rate, or if the patient prefers, then carioversion with either DC or pharmacological methods are appropriate. If the condition occurs for more than 48 hours the patient should be placed on anticoagulation therapy with warfarin. The target INR is 2-3.

Rate control can be accomplished with Beta-blockers (Toprol XL, Lopressor, Atenolol, Coreg) or calcium channel blockers (diltiazem or verapamil). If the patient has heart failure digoxin may also be used. Rate control is defined as resting heart rate less than 80, 24 hour Holter monitor with average heart rate less than 100, and heart rate during 6 minute walk of less than 110.

Rhythm control is accomplished via DC cardioversion or pharmacologic medications such as amiodarone. Acute indications of cardioversion include: active ischemia, significant hypotension, severe manifestations of heart failure, and presence of a preexcitation syndrome. If there is time it may be beneficial to obtain a transesophageal ultrasound prior to the procedure to rule out a thrombus that could lead to a stroke or heart attack.

Anticoagulation should occur in patient’s with a fib greater than 48 hours, paroxysmal a fib, or while restoring normal sinus rhythm. Medications include warfarin therapy or aspirin. If the patient has contraindications to warfarin therapy then use aspirin. Otherwise warfarin was the recommended medication. The goal of treatment is an INR of 2-3.

Other treatments:
Blood pressure control with class of drugs called ACE inhibitors and Angiotension receptor blockers (ARBs).

So I wonder if these extremely healthy individuals are actually damaging their hearts? Based on the above information you be the judge.


References:
Uptodate.com

This sounds familiar!!!

Prufrockian (pru-FROK-i-uhn) adjective

Marked by timidity and indecisiveness, and beset by unfulfilled
aspirations.

Yet another intern!!

I've recently acquired a fascination for politics. My commutes have been filled with the rhetoric of Rush Limbaugh and Hannity. Although, I cannot agree with everything they speak,I still find them entertaining at least. Rush recently discussed the 2008 Presidential race. He was commenting on a Clinton vs. Condi race.

I was struck by this thought, a thought one should not contemplate while driving 15 miles per hour over the speed limit on a perfect race track two lane road.

Let's, for entertainment sake, say Hillarious Clinton is elected to the Oval Office. If I'm not mistaking that would make Hill Billy Clinton the "First Gentlemen." With this comes many responsibilities, such as:

1. hosting during receptions at the Presidential residence;
2. advocating on behalf of public causes and charities;
3. accompanying their spouse in official travel abroad;
4. State functions and other like duties.

Will the "First Gentleman" have an intern to assist in his affairs (no pun intended)? Will it be Monica Lewinsky? Will the new President allow such an assistant for her adulterous husband? Will there be new legislation passed down by the White House?

Then it raises the question, what will occupy Hill Billy while his wife negotiates nuclear treaties with Russia? Will he have tea and vodka with Putin's significant other? Will he have sexual relations with Putin's significant other?

For the conspiracy theorist's, will he use this as a way to acquire a third term in the office legally? Or better yet, will this be Hillarious' third term? Time will only tell. Until then, Da sveedaneeya!! Pratty