Atrial fibrillation ( AF ) is a common sustained cardiac arrhythmia. ( 1, nice ) . AF is described as uncoordinated atrial activation which leads to deterioration of the map of atrial. The atria will quake instead than contract due to the irregular electrical urges and therefore, the efficiency of the atria to pump blood into ventricles are disrupted. AF occurs when difference in stubborn period within atrial tissue happens and this is usually caused by coexistence of fibrosis and healthy atrial musculus fibers in the atria ( 1 ) . The hazard factors of germinating AF include aging, diabeties, hypertention, valve disease. ( nice ) Dietary and life style can besides precipitate hazard of AF, such as intoxicant or caffeine ingestion and emphasis. White Caucasians are the most presenters among the informations. In UK, the prevalence of AF is about 1 % of the population. It is more common in males than females. The prevalence besides rises with aging. ( 4 ) AF can be symptomless or comes with symptoms such as shortness of breath, palpitations, giddiness and thorax hurting. AF can be diagnosed based on EKG ( ECG ) if irregular pulsation is detected ( 1 ) . Absence of P moving ridges, irregular ventricular beat, or irregular baseline fluctuations can be an indicant of AF. ( 5 ) Atrial rate can make 350-600 beats per minute while ventricles rate runing from 100 to 180 beats per minute. Other trial such as echocardiogram is carried out to help in placing any other bosom disease like shot hazard factors, chest x-ray to look into if there is any lung job due to AF, and eventually blood trial, which can be utile as anemia or thyrotoxicosis may perplex AF. ( 3 ) AF is classified into few classs based on the clinical characteristics. These are paroxysmal AF ( AF halt spontaneously in less than 7 yearss and often within 2 yearss ) , persistant AF ( AF non self ending, persist for more than 7 yearss or anterior to cardioversion therapy ) and lasting AF, which is non ending or get worse upon expiration. Recurrent may happen in paroxymal and persistant AF while lasting AF shows established form. ( nice ) AF increases the hazard of acquiring bosom failure, thromboembolism and shot. Trend of morbidity and mortality due to AF in Scotland between 1986 and 1996 was studied and it showed that hospitalizations with AF have increased 2 to 3 creases. Number of deceases and shots associated with AF has increased every bit good. ( 6 )

Atrial fibrillation is complicated with congestive cardiac failure ( CCF ) ( or congestive bosom failure ) and shot. ( NICE ) In this instance, the patient was presented with decompensated CCF. CCF is a status where the bosom is unable to bring forth sufficient cardiac end product to run into the metabolic demands of the organic structure. In add-on, addition in venous force per unit area causes accretion of fluid in lungs and organic structure, taking to congestion. These two cardiac diseases are highly linked together. Patient with either upset may hold increased hazard of developing the other. Coexist of both disease carries a worse forecast. A survey was performed to look into the relationship between AF and CCF and the coexistence of both diseases influence on mortality. 921 patients that were diagnosed with AF, 238 of them had CCF while another 144 developed it subsequently. Another 931 patients with CCF, AF was diagnosed in 24 % of the patients while 17 % developed it subsequently. Animal surveies showed that rapid ventricular response in AF can take to dilated cardiac musculus disease. Lost of atrial conveyance taking to diminish in cardiac end product may do CCF. On the other manus, CCF may do rapid atrial filling force per unit area and atrial distension. It besides causes atrial fibrosis and unnatural impulse conductivity, which so predispose to AF. Medications available for AF and CCF are beta blockers, Lanoxin, angiotonin change overing enzyme inhibitor and angiotonin receptor blocker. Beta blocker is beta adrenoreceptor adversary which selectively blocks & A ; Icirc ; ?1- and & A ; Icirc ; ?2- receptor. Metoprolol selectively acts on & A ; Icirc ; ?1- receptors in the bosom which leads to diminish in bosom rate. ( RND ) Digoxin is a cardiac glycoside. It increases parasympathetic activity and inhibit Na+/K+ pump. It slows down AV conductivity taking to bosom rate lessening. Inhibition of Na+/K+ pump leads to decelerate bulge of Ca+ . This causes addition in release of Ca during action potency, taking to increased contractility of the bosom. 2 chief interventions for AF and CCF are rate and beat control. ( NICE ) Rate control aims at cut downing the rapid bosom rate by utilizing chronotropic drugs or surgery while beats control involves the application of cardioversion to alter the arrhythmia caused by AF back to normal fistula beat. Cardioversion is available in 2 signifiers, electrical and pharmacological intercession, which uses antiarryhthmic drugs. However, the most appropriate starting intervention for patient is still remain contention. Patient treated with either of the intervention needs antithrombotic therapy to forestall thromboembolic events. Warfarin is an decoagulant. It inhibits Vitamin K reductase, therefore interfering coagulating factors II, VII, IX and X. Furosemide was given to this patient due to oedema. Furosemide acts on the go uping cringle of Henle, inhibits the Na+/K+/2Cl- bearer, therefore prevents the resorption of NaCl and increases elimination of H2O. ( RND ) Potassium addendum can be given to forestall hypokalemia.

Initial therapy for AF is problematic. Care of fistula beat ( normal beat ) by antiarrhythmic drugs is frequently used as the get downing therapy as if consequences in less symptoms, better effort tolerance, lower hazard of shot following discontinuance of long term anticoagulant therapy and better quality of life. However, the respond of AF towards antiarrhythmic drugs is hapless usually, and associated with serious side effects excessively. Another attack towards AF is rate control therapy. It is more simple and less toxic compared to antiarrhythmic drugs, nevertheless, anticoagulation becomes more of import. ( 8 ) Consequences showed that the figure of intervention crossing over was significantly higher in the group of patient that received beats control therapy as initial therapy ( due to therapy failure ) . An increased in mortality rate was besides identified in the beat control group. Patients in the beat control group were associated with higher event of hospitalizations and side effects every bit good. The analysis concluded that rate control therapy should be considered as chief therapy if rhythm control does non bring forth satisfactory consequence. ( 8 ) Another survey was conducted to compare the effectivity of beat control and rate control in patients with AF and CCF. Among the 1009 patients, 2-year mortality rate is checked and consequences showed that there was no important difference between both of the groups ( 31 % from rate control versus 29 % from rhythm control ) . ( 9 ) There was no important difference in the quality of life between the group treated with electrical cardioversion and patient assigned with rate control as good. ( 9 ) Class I agents of antiarrythmic drugs increased mortality and it should be avoided in patient with structural bosom disease. ( specific ) ( 10 )

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Harmonizing to NICE guidelines, lasting AF is treated with rate control therapy. In many patient with CCF and AF, beat control is improbable to win ( 10 ) Therefore, rate control plays of import portion as rapid bosom rates can decline map of left ventricle, which so precipitate CCF. Digoxin, beta blocker and Ca channel blocker ( CCB ) are usually used. Digoxin has been used for long clip in the intervention of AF, it is besides utile in the direction of CCF as it has negative inotropic consequence nevertheless, it shows less efficaciousness in commanding the bosom rate during effort. ( nice ) Combination therapy of Lanoxin and beta blocker is usually used for AF that is non well-managed with a individual therapy. A retrospective analysis was carried out to look into the usage of beta blocker ( carvedilol ) on 136 patients with attendant AF and CHF. 84 patients were given carvedilol while the remainder were assigned with placebo. Therapy with carvedilol showed a important betterment in left ventricular expulsion fraction ( reduced in expulsion fraction can attest bosom failure ) compared to placebo. It besides showed decrease in mortality or hospitalizations due to CCF. ( 11 ) Consequence of Lopressor CR/XL in congestive bosom failure was investigated every bit good. Patients in New York Heart Association ( NYHA ) functional category II to IV and with expulsion fraction 0 to 40 or less, stabilized were included into the survey. All cause of mortality was lower among patients treated with Lopressor. The same tendency goes to sudden deceases and deceases due to impairment of bosom failure. ( 12 ) Survey on 5 drugs ( Lanoxin, diltazem, Tenormin, Lanoxin and atenolon, Lanoxin and diltazem ) was performed to compare 24 hours ventricular rate in patient with chronic AF. The mean of VR was lowest in patients with combination therapy of Lanoxin and Tenormin. This combination therapy showed important lower VR than on Lanoxin, diltazem and atenolol entirely. It besides resulted in lowest average VR during exercising. This concluded that combination therapy of Lanoxin and beta bloker produced most promising consequence in commanding bosom rate, and besides reflected that interactive consequence of this 2 drugs might be utile for future development. ( 13 ) The effectivity of combination therapy of beta blocker and Lanoxin was besides examined in another survey. 47 patients with relentless AF and bosom failure were enrolled into this survey. The survey was separated into two stages: in 1st stage, efficaciousness of Lanoxin is compared with combination therapy of Lanoxin and carvedilol for 4 months while in 2nd stage, Lanoxin of the combination therapy was taken out in a double-blinded mode, therefore comparing between Lanoxin and carvedilol can be made. This stage lasted for 6 months. Combination therapy showed better result as average 24 hours-ventricular rate was significantly reduced. The symptom tonss, left ventricular expulsion fraction ( LVEF ) and NYHA besides showed betterment. In stage 2, backdown of Lanoxin from the combination therapy resulted in a important addition in the 24-hours average bosom rate and lessening in LVEF. There was no important difference between carvedilol and Lanoxin noted in the parametric quantities. ( carve and digo ) NICE guidelines recommend that in patient with AF and necessitate rate control therapy, beta blockers or rate-limiting CCB should be the chief therapy, and if mootherapy is non equal, Lanoxin can move as accessory therapy.

Antithrombotic therapy is usually provided to patient with lasting AF to forestall ischemic shot and other thromboembolic events. 9 % to 20 % of AF Patients with vulvular bosom disease such as mitral stricture will develop shot. Aged and patients with hapless bosom map are besides at higher hazard of developing systemic emboli. ( nice ) Anticoagulant such as Coumadin and antiplatelet like acetylsalicylic acids are usually used in this therapy. A meta-analysis was carried out to find the efficaciousness and safety of Coumadin and acetylsalicylic acid for shot bar in patients with AF. 16 tests which covered 9874 patients were included into the meta-analysis. Adjusted-dose Coumadin and acetylsalicylic acid were proved to be effectual in cut downing per centum of shot among the patients. In add-on, Coumadin shows better outcome so aspirin, nevertheless, it increased major extracranial hemorrhage every bit good. ( 14 ) A systemic reappraisal was done on 5 randomised controlled tests ( RCT ) to measure the long term direction of anticoagulation and antiplatelet in patients with non-rheumatic AF ( no bosom valve harm ) . There was no important difference in mortality due to stroke. Non-fatal shot occurred more significantly in patients with antiplatelet therapy. More events of shed blooding in patients treated with anticoagulation therapy were observed. However, the consequence showed deficiency of uniformity among the 5 tests therefore ensuing in uncertainness about the effectivity of long term anticoagulation and antiplatelet therapy. ( systemic ) International normalized ration ( INR ) values dramas of import function in finding the hazard of shot or other thromboembolic events and hemorrhage. The hazard of shot in patient with AF is said to be greatly reduced by anticoagulation and INR values of 2.0 and greater. A group of patient with nonvulvular AF was studied to analyze the usage of Coumadin and acetylsalicylic acid and besides INR value. Consequences showed patients that were taking Coumadin with INR less than 2.0 ( 1.5 to 1.9 showed similar tendency with INR less than 1.5 ) have higher figure of shot and hazard of decease compared to patient taking warfarin with INR greater than 2. The mortality rate of patients taking acetylsalicylic acid besides showed the same tendency. This survey concluded that Coumadin or acetylsalicylic acid produces full consequence of anticoagulation at INR values of 2 or greater. ( INR ) Combination of Coumadin and acetylsalicylic acid does non bring forth interactive consequence in anticoagulation therapy but increases the hazard of shed blooding. Therefore, attendant usage of acetylsalicylic acid and Coumadin is non encouraged. NICE guidelines recommend that in patients with lasting AF, appraisal of hazard and benefit should be performed and discussed with the patient before antithrombotic therapy is given. For those that need the therapy, adjusted-dose Coumadin should be given, with a mark INR scope 2.0 to 3.0. Aspirin with a dosage of 75mg to 300 milligrams should be given if Coumadin is non appropriate for the patient.