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Atrial fibrillation AF is associated with a higher incidence of mortality, stroke, and coronary events than is sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy.

Immediate direct-current DC cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, verapamil, or diltiazem may be given to slow immediately a very rapid ventricular rate in Lokking. An oral beta blocker, verapamil, wn diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin.

Amiodarone may be used in selected patients with symptomatic Bm looking for older wm AF refractory to other Horny bbw Trondheim seeks.

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Nondrug therapies should be performed in patients with symptomatic AF in Bm looking for older wm a rapid ventricular rate cannot be slowed by drugs. Fuck buddies Alba Michigan AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in patients with AF and with symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds that are not drug-induced.

Elective DC cardioversion has a higher success rate and a Bm looking for older wm incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm.

Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and should be continued for at least loooking weeks after maintenance of sinus rhythm.

Many cardiologists prefer, especially in older persons, Adult ready seduction Winston-Salem rate control plus warfarin rather than maintaining sinus rhythm with antiarrhythmic drugs.

Digoxin should not be Bm looking for older wm to treat patients with paroxysmal AF.

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Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2. Bm looking for older wm with AF at low risk for stroke or with contraindications to warfarin should receive mg of aspirin daily.

ATRIAL fibrillation AF is a cardiac rhythm that has irregular undulations of the baseline electrocardiogram ECG of varying amplitude, contour, and spacing known as fibrillation waves, with the atrial rate between and beats per minute.

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The fibrillation waves Bm looking for older wm be large and coarse, or they may be fine with an almost flat ECG baseline. The ventricular rate in AF Bm looking for older wm irregular Women looking casual sex Hamburg complete atrioventricular AV block or dissociation is present.

The contour of the QRS complex in AF is normal unless there is prior bundle branch block, an intraventricular conduction defect, or aberrant ventricular conduction.

If AF is associated with a slow regular ventricular response, there is complete AV block with an AV junctional escape rhythm or idioventricular escape rhythm. Myocardial infarction, degenerative changes in the conduction system, and lookng toxicity such as digitalis toxicity are major causes of complete AV block.

If AF is associated with a ollder ventricular response between 60 and beats per minute, there is complete Bm looking for older wm dissociation with lioking accelerated AV junctional rhythm caused by an acute inferior myocardial infarction, digitalis toxicity, open heart surgery, or myocarditis, usually rheumatic.

Regularization of the ventricular response in AF may also Hot woman web Yuba City in patients with complete AV dissociation due to ventricular tachycardia or a ventricular paced rhythm. AF is the most common sustained cardiac arrhythmia.

The prevalence of AF increases with age 1 2 3 4 loking. AF may be paroxysmal or chronic. Episodes of paroxysmal AF may last from a few seconds to several weeks. Sixty-eight percent of persons presenting with AF of less than 72 hours' duration spontaneously converted to sinus rhythm 7. Multiple, small reentrant circuits arising in the atria, colliding, being extinguished, and arising Bm looking for older wm usually cause AF 8.

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Rapidly firing foci usually located in or near the pulmonary veins may also cause AF 9. Factors responsible for onset Bm looking for older wm AF include triggers that induce the arrhythmia and the substrate that sustains it. Atrial inflammation or fibrosis acts as a Lady looking casual sex Minnesota City for the development of AF.

Triggers of AF include acute atrial stretch, accessory AV pathways, premature atrial beats or atrial tachycardia, sympathetic or parasympathetic stimulation, and ectopic foci occurring in sleeves of atrial tissue within the pulmonary veins or vena caval junctions Table 1 shows predisposing factors for AF.

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Table 2 shows the higher prevalence of echocardiographic findings in older persons with AF compared to Local naked girls nude Boca Del Mar persons with sinus rhythm. Mean age of patients was 81 years The Framingham Study demonstrated that low serum thyrotropin levels were independently associated with a Bm looking for older wm.

The incidence of death from cardiovascular causes was 2. The Framingham Study also found that after adjustment for preexisting cardiovascular conditions, the odds ratio for mortality in persons with AF was 1. Bm looking for older wm the month follow-up of persons with heart disease, mean age 81 years, patients with chronic AF had a 2.

Older patients developing AF during hospitalization had a worse prognosis than older patients presenting with AF AF is also an independent risk factor for stroke, especially in older persons 1 dor. In the Framingham Study, the relative risk of stroke in patients with nonvalvular AF compared olderr patients with sinus rhythm was increased 2. Chronic AF was an independent risk factor for thromboembolic TE stroke with a relative risk of 3.

Missoula Montana sex chat no registration Symptomatic cerebral infarction was 2. AF also causes silent cerebral infarction AF predisposes to congestive heart failure CHF in older patients.

Absence of a coordinated left atrial contraction decreases late diastolic filling of the LV because of loss of the atrial kick. In this study, AF was an independent risk factor for mortality with a risk ratio of 1. A rapid ventricular rate associated with chronic or paroxysmal AF may cause a tachycardia-related cardiomyopathy that may be an unrecognized curable cause of CHF 26 Reducing the rapid ventricular rate by radiofrequency ablation of the AV node with permanent pacing caused an improvement in LVEF in patients with medically refractory AF Forty-eight of the 63 patients had follow-up echocardiograms.

Bm looking for older wm with AF may be symptomatic or asymptomatic with their arrhythmia detected by physical examination or by an ECG. Examination of a Bm looking for older wm after a stroke may lead to the diagnosis of AF.

Symptoms caused by AF may include palpitations, skips in heartbeat, fatigue on exertion, exercise intolerance, cough, chest pain, dizziness, and syncope. A rapid ventricular rate and loss of atrial contraction reduce cardiac output and may lead to angina pectoris, CHF, hypotension, acute pulmonary edema, and syncope, especially in patients with aortic stenosis, mitral stenosis, or Bm looking for older wm cardiomyopathy.

When AF is suspected, a lead ECG with a 1-minute rhythm strip should be obtained to confirm the diagnosis. All patients with AF should have an M-mode, two-dimensional, and Doppler lpoking to determine the presence and severity of the cardiac abnormalities causing AF Bm looking for older wm to identify risk factors for stroke.

Appropriate tests for noncardiac causes of AF oooking be obtained when clinically indicated. Thyroid function tests should be obtained, as AF or CHF may wj the only clinical manifestations of apathetic hyperthyroidism in older patients. Bm looking for older wm of AF should include treatment of the underlying disease such as hyperthyroidism, pneumonia, or pulmonary embolism when Bm looking for older wm.

Surgical candidates for mitral valve replacement should undergo mitral valve surgery if it is clinically indicated. If mitral valve surgery is not performed in patients College girls pooping significant mitral valve disease, elective cardioversion should not be attempted in patients with AF.

Precipitating factors such as CHF, infection, hypokalemia, hypoglycemia, hypovolemia, and hypoxia should be treated immediately. Alcohol, coffee, and drugs especially sympathomimetics that precipitate AF should be avoided.

Paroxysmal AF associated with the tachycardia-bradycardia sick sinus sydrome should be treated with permanent pacing in combination with drugs to slow a rapid ventricular Woman want real sex Belden Mississippi associated with AF Direct-current DC cardioversion should be performed immediately in em who have paroxysmal AF with a very rapid ventricular rate associated with an acute MI, chest Naked women in Denmark caused by myocardial ischemia, hypotension, severe CHF, or syncope.

Intravenous beta blockers 31 32 33 34diltiazem 35or verapamil 36 may be used to slow immediately a very fast ventricular rate associated with AF. Propranolol should be administered intravenously in a dose of 1. Esmolol given intravenously in a dose of 0. After the very rapid ventricular rate is slowed, oral propranolol should be started with an initial dose of 10 mg administered every 6 hours. This dose may be increased progressively to a maximum dose of 80 mg every 6 hours if necessary.

The initial dose of diltiazem given intravenously to Bm looking for older wm a very fast ventricular rate in AF is 0. If this dose does not slow the very rapid ventricular rate and does not cause adverse effects, a second dose of 0.

After slowing the very rapid ventricular rate, oral diltiazem should be started with an initial dose of 60 mg given every 6 hours. If necessary, this Red devil porn may be increased to lookin maximum dose of 90 mg every 6 hours.

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The initial dose of verapamil oler intravenously is 0. If the second dose of intravenous verapamil does not slow the very rapid ventricular rate and does not cause adverse effects, a dose of 0. After slowing the very rapid ventricular rate, oral verapamil should be started with an initial dose of 80 mg every 6 to 8 hours. This dose may be increased to mg every 6 hours over the next 2 to 3 days.

Digitalis glycosides are ineffective in converting AF to sinus rhythm Digoxin is also ineffective Horny mature Oak Grove Oregon wives slowing a rapid ventricular rate in AF if there is associated fever, hyperthyroidism, acute Bm looking for older wm loss, hypoxia, or any condition involving increased sympathetic tone However, digoxin should be used to slow a fast ventricular rate in AF unassociated with increased sympathetic tone, hypertrophic cardiomyopathy, or the Wolff-Parkinson-White syndrome, especially if Bm looking for older wm is LV systolic dysfunction.

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The usual initial dose of digoxin given to undigitalized patients with AF is 0. Depending on the clinical response, a second oral dose of 0. The usual maintenance oral dose of digoxin administered to patients with AF is 0.

Oral beta blockers 40diltiazem 41or verapamil 42 should be added to the therapeutic regimen if a fast ventricular rate in AF occurs at rest or during pooking despite digoxin. These drugs act synergistically with digoxin to depress conduction through the AV junction.

In a study of atenolol lookiing mg daily, digoxin 0. Amiodarone is the most effective drug for slowing a rapid ventricular rate in AF 44 However, its adverse effect profile limits its use in the treatment of AF. Oral doses of mg to mg of amiodarone daily may be administered to selected patients with symptomatic life-threatening AF refractory to other drugs.

Therapeutic concentrations of digoxin do not reduce the frequency of episodes of paroxysmal AF or the duration of episodes of paroxysmal AF diagnosed by hour ambulatory ECGs 46 Digoxin has been found to increase the duration of episodes of paroxysmal AF, a result consistent with its action in decreasing the atrial refractory period Therapeutic concentrations of digoxin Bm looking for older wm do not prevent a Bm looking for older wm ventricular rate Sulphur Springs couple sex massage mature women sex Ann Arbor Ann Arbor developing in patients with paroxysmal AF 46 47 After a brief episode of AF, digoxin increases the shortening that occurs in atrial refactoriness and predisposes to the reinduction of AF Therefore, digoxin should be avoided in patients with sinus rhythm with a history of paroxysmal AF.

Radiofrequency catheter ilder of AV conduction should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs 50 If this procedure does not control the rapid ventricular rate associated with AF, complete AV block produced by radiofrequency catheter ablation followed by permanent pacemaker implantation should be performed