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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Heart rates up to 150 bpm

  • Three or more distinct P waves in a single lead

  • Variable P-P, P-R, and R-R intervals

  • A majority (60–85%) of cases are associated with pulmonary disease

GENERAL CONSIDERATIONS

  • Accounts for < 1% of all arrhythmias

  • Chronic obstructive pulmonary disease exacerbation is the most common condition in which this arrhythmia is seen

  • Respiratory failure, decompensated heart failure, and infection may precipitate the condition

  • Hypokalemia, hypomagnesemia, and hyponatremia may be associated with this arrhythmia

  • Pulmonary embolism, valvular heart disease, and postoperative state may rarely be associated with this arrhythmia

  • Abnormal automaticity is the most likely mechanism, although triggered activity is also proposed

  • Multifocal atrial tachycardia is often misdiagnosed as atrial fibrillation due to the irregularity in the R-R interval

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Most of the symptoms are related to the underlying cause

  • Most patients are short of breath secondary to underlying lung disease

  • Palpitations

  • Chest pain

PHYSICAL EXAM FINDINGS

  • Variable S1

  • Other findings relate to underlying cause

DIFFERENTIAL DIAGNOSIS

  • Atrial fibrillation

  • Atrial flutter

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC, basic metabolic panel

  • Arterial blood gas analysis

  • Cardiac biomarkers if there is a suspicion of myocardial infarction

  • Chest x-ray and other investigation toward managing the underlying cause

ELECTROCARDIOGRAPHY

  • ECG shows tachycardia with 3 or more distinct P waves in a single lead and variable P-P, P-R, and R-R intervals

IMAGING STUDIES

  • Occasionally an echocardiogram may be used to assess right and left heart function

TREATMENT

CARDIOLOGY REFERRAL

  • If patients are hemodynamically unstable

  • If ventricular rate could not be controlled using conventional atrioventricular (AV) nodal blocking drugs

HOSPITALIZATION CRITERIA

  • Most patients are hospitalized because of underlying respiratory failure

MEDICATIONS

  • Treat the underlying cause (ie, respiratory failure)

  • Verapamil is useful, 180–360 mg/day

  • Cardiac selective beta blockers, such as metoprolol, may be used for ventricular rate control if tolerated

  • Intravenous magnesium and potassium supplementation may convert a significant number to sinus rhythm

  • Digoxin is usually not helpful and has the potential to initiate atrial tachycardia

  • Theophylline and beta agonists should be titrated down to the least effective dose

THERAPEUTIC PROCEDURES

  • In a rare patient, pacemaker implantation followed by AV nodal ablation may be required

MONITORING

  • ECG monitoring in the hospital

DIET AND ACTIVITY

  • As appropriate for the underlying cause

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA
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