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Clinical presentation

The patient may experience palpitations, shortness of breath, syncope or chest pain and a reduced cardiac output.

Characteristic features of the ECG

• P waves are absent; instead oscillating f (fibrillation) wavelets can be seen (Figure 8.8).

• PR interval not measurable.

• Atrial rate may be very rapid and difficult to determine.

• No identifiable relationship between the P waves and QRS complexes.

• QRS rate may be slow or fast and the rhythm will be irregular.

• QRS width is within normal parameters (Goodacre & Irons 2002).

• Chronic pulmonary disease

• Acute or chronic alcohol misuse

• Thyrotoxicosis

• Cardiomyopathies

• Rheumatic valve disease

Response

Treatment options for those classified as intermediate risk take into account evidence of haemodynamic status, whether the onset of AF occurred within 24 hours and the presence of structural heart disease (ERC 2001). A heparin infusion followed by emergency electrical cardioversion (see Chapter 9) should be considered for high-risk patients. If cardioversion is unsuccessful or AF recurs, intravenous amiodarone 300 mg should be administered over one hour before attempting cardioversion again (Resuscitation Council UK 2000). Management also involves addressing the reversible causes immediately, aiming to:

• control the rate by slowing ventricular response;

• control rhythm by conversion to sinus rhythm;

• restore haemodynamic functioning and circulation;

• maintain sinus rhythm and prevent further episodes.

The time of onset and haemodynamic stability of the patient are variables which will affect treatment decisions (ERC 2001).

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