Talk:Atrial fibrillation

From Wikipedia, the free encyclopedia
Jump to: navigation, search
WikiProject Physiology (Rated Mid-importance)
WikiProject icon This article is within the scope of WikiProject Physiology, a collaborative effort to improve the coverage of Physiology on Wikipedia. If you would like to participate, please visit the project page, where you can join the discussion and see a list of open tasks.
 ???  This article has not yet received a rating on the quality scale.
 Mid  This article has been rated as Mid-importance on the importance scale.
Taskforce icon
This article has not yet been associated with a particular area.
 
WikiProject Medicine / Cardiology (Rated B-class, Mid-importance)
WikiProject icon This article is within the scope of WikiProject Medicine, which recommends that this article follow the Manual of Style for medicine-related articles and use high-quality medical sources. Please visit the project page for details or ask questions at Wikipedia talk:WikiProject Medicine.
B-Class article B  This article has been rated as B-Class on the project's quality scale.
 Mid  This article has been rated as Mid-importance on the project's importance scale.
Taskforce icon
This article is supported by the Cardiology task force (marked as High-importance).
 
Note icon
This article was previously a Medicine Collaboration of the Week.

What this article needs[edit]

This article needs:

  • Some basic electrophysiology - where do action potentials originate, what perpetuates them, what determines whether the impulse is conducted by the AV node.
  • A good list of risk factors
  • Images of 12-lead ECGs with perhaps an example of PAF or atrial flutter
  • Links to international guidelines for treatment, anticoagulation, cardioversion and surgery/EP ablation
  • Burden of disease in the Western world, contribution to stroke incidence, perhaps also see if there are studies on the cost of anticoagulation services for AF and whether rhythm control could modify this!
  • Is there historical information on the disease entity, eponyms etc.

I'll try to help along on this one! JFW | T@lk 15:34, 21 December 2005 (UTC)

It's a good framework, for sure. There's a lot of jargon and not many references. I think that the causes section needs to be converted into text. Lone AF is absent and more could be said about structural heart disease causing AF. The role of AF in precipitating failure in MS/AS, etc. should also be mentioned. I've been on the cardiac step-down unit the last few weeks (the Smack-down) but should now have some time in the next few weeks to contribute. InvictaHOG 23:36, 26 December 2005 (UTC)
  • Autonomic nervous system influences Bob K31416 (talk) 17:04, 14 June 2008 (UTC)
  • Status of approval by EU and USA regarding the use of various drugs and devices for treating AF; off-label use --Bob K31416 (talk) 19:47, 15 July 2008 (UTC)
  • I was advised by my doctor of a technique to end an A-Fib episode and it works - to take a deep breath and bear down like pilots do in the G-force machine to keep from passing out. This works, but I have seen no reference to this very helpful technique in any of the A-Fib literature on the net. Perhaps a medical professional could write something on this please? 70.72.26.188 (talk) 07:33, 13 September 2008 (UTC)
See Valsalva maneuver. --Bob K31416 (talk) 11:30, 13 September 2008 (UTC)
Works for some. Others, like myself can sometimes get out of afib by hard exercise or even coughing, if done quickly after onset(or just getting damn angry, lol). Sex works for others. —Preceding unsigned comment added by 58.178.191.215 (talk) 07:41, 14 January 2011 (UTC)

section 6.5.1 anti-arrhythmic agents[edit]

says AF can be controlled with Na+ chan blockers (Class I) or K+ chan blockers (Class II). but class II = beta-blockers, and K+ block = Class III. So is the treatment with K+ block or class II? I would guess at K+ (Class III) but guesses arent encyclopaedic —Preceding unsigned comment added by 87.194.78.179 (talk) 17:48, 20 May 2009 (UTC)


"Maze" v. "maze" procedure[edit]

I left a similar comment on Jamesmcclelland's page. I've lowercased the "maze" in "Cox maze procedure" given that maze is not a proper noun. It would be akin to capitalizing "forceps" in "Debakey forceps" or "clamp" in "Kocher clamp." A casual pubmed search shows that maze is also in lowercase. Andrew73 02:31, 28 December 2005 (UTC)

jamesmcclelland here. It's been used both ways, but it seems that James Cox, who invented the procedure, prefers that "maze" be capitalized to "Maze". I agree that this doesn't make too much sense, but that's how it has usually been done. See his recent publication for instance:

Cox JL. The Role of Surgical Intervention in the Management of Atrial Fibrillation. Tex Heart Inst J. 2004; 31(3): 257–265. PMID 15562846

I left it uncapitalized anyway, rather than go around and around.

Thanks for finding the reference. While Cox may have capitalized "maze" in the original article, the majority of the published literature from what I've seen uses it in the lower case version. It seems that the capitalization is a little bit idiosyncratic, almost an affectation! Andrew73 20:19, 2 January 2006 (UTC)
Actually, I think it's an "attibution" thing; that is, "maze" is relatively generic, whereas "Maze" refers to the procedure he developed. My impression of how the terms are used is that if it's an actual Cox Maze (that is, if Cox was associated with it) - such as the original Cox Maze, the Cox Maze II, the Cox Maze III, or the (can you believe it) Cox Maze IV, it is capitalized. Also, *his* version of the MiniMaze. When others make variations on the theme, such as the various "minimaze" procedures, it is not capitalized. I think that's why you are seeing that much of the literature is uncapitalized.
Here's my position: Cox is indeed the originator of this field of arrhythmia surgery for AF, and I think that it's reasonable to recognize that by things like capitalizing the original Maze(s) as he does. I'd leave other mazes lowercase. This is consistent with the literature in my opinion. What do you think? jamesmcclelland 22:48, 2 January 2006 (UTC)
Interestingly, while "maze" is capitalized in the Texas Heart Journal reference, there are multiple other references authored by Cox where "maze" is left uncapitalized, e.g. PMID 8215657. I'd be curious to hear what others think! Andrew73 22:58, 2 January 2006 (UTC)
We could flip a coin! InvictaHOG 02:31, 3 January 2006 (UTC)
Hmmm... coin flip via internet? The reference you (Andrew73) have cited is from 1993, after his first 75 patients. It was substantially later that other "Maze-like" procedures began to be published and the issue of distinguishing between these procedures became important. jamesmcclelland 04:12, 3 January 2006 (UTC)
Flip the coin here: http://www.random.org/flip.html Now we only have to choose which coin to flip... :) --WS 04:38, 3 January 2006 (UTC)
I will wait a few days and see if anyone else weighs in. jamesmcclelland 07:25, 3 January 2006 (UTC)
I'm having a terrible time convincing people that the procedure was not co-invented by Dr. Maze, and that MAZE is not an acronym for something. Leaving "maze" uncapitalized helps people understand that it's called a Cox maze procedure because it's like a maze.--Mark D Hardy 16:40, 19 May 2006 (UTC)

Lone afib[edit]

I added a little regarding LAF and made some stylistic changes. --DocJohnny 10:19, 30 December 2005 (UTC)

Symptoms[edit]

That AF can be asymptomatic is implied in the text, but I felt it would be better to directly state this as it may not be clear to a lay reader --Mattopaedia 07:42, 31 December 2005 (UTC)

Electrocardiogram[edit]

Drawing of the EKG, with labels of intervals
P=P wave, PR=PR segment, QRS=QRS complex, QT=QT interval, ST=ST segment, T=T wave.

Is it worthwhile including this image from electrocardiogram (or something like it) to give the reader some instant idea of what is meant by "absence of P waves" etc? --Mattopaedia 07:49, 31 December 2005 (UTC)

I say, be bold and add it! Though it might be better if we duplicated it into several cardiac cycles to show its regularity InvictaHOG 22:55, 2 January 2006 (UTC)

More about classification and treatment[edit]

I have clarified classification based on ACC/AHA guidelines. But more needs to be done to organize the treatment section, especially in regards to initial episode vs. recurrent. I will try to tackle those later. --DocJohnny 17:54, 31 December 2005 (UTC)

Also, I have added references in the forms in in text links, I am unfamiliar with the format used for endnotes. Perhaps a kind bot will assist in formatting. --DocJohnny 13:40, 1 January 2006 (UTC)

External Links[edit]

Hi, I am new to this site but I have found a great website that offers the most in-depth, physician reviewed content on Atrial Fibrillation that I have seen. I tried to add the link but was told it would be removed---and it was. The link to the content is here: http://www.medifocushealth.com/CR004/atrial_fibrillation.php---If you (like me) think its good content, can you tell me how I can add this resource so others may benefit? Thanks.

While the content is of reasonable quality, it is supported with Google ads. Most of the material on the AF page on Medifocushealth should actually already have been incorporated into this Wikipedia article. In that sense, I do not support inclusion of the link.
I see you are alphabetically linking all the pages from that site on Wikipedia. This is spam and I would strongly discourage you from doing this. Wikipedia is not a way to improve site traffic. JFW | T@lk 05:10, 21 December 2006 (UTC)

In the illustration of pathophysiology I believe that the illustration is incorrect in that it shows the wave propagating down the heart. The impluse actually goes down the Bundle of His and then the depolarization of the heart begins the bottom of the heart and works it way up. The squeezing of the heart must begin from the bottom if you think about it as the exit valves are not at the bottom of the heart but roughly in the middle. I would appreciate further commentary from an expert electrophysiologist. Thomas

Normal vs AFib conduction image[edit]

This is in response to a stray post under External Links talk. Under Pathophysiology, the GIF comparing normal conduction v AFib conduction is misleading. This appears to be an artists rendition rather than a medically acurrate and informative image. The conduction goes from the Sinus node to the muscle of the atria to the HIS bundle as shown, but then goes down the Purkinje Fibers down the center of the Ventricular septum. It then activates through the heart muscle from the Apex up to the base of the ventricles. I'll try to find an Image or set of images that would be more accurate.Nbrysiewicz 22:52, 24 March 2007 (UTC)

Here is a GIF of normal sinus rhythm. I don't know how to edit GIFs otherwise I would have made an example of AFib using this GIF. I need help to make this page more accurate. If anyone can, please replace the images with corrected GIFs. http://en.wikipedia.org/wiki/Image:ECG_Principle_fast.gif Nbrysiewicz 00:59, 25 March 2007 (UTC)

Afib vs sinus[edit]

Just looking at the example of supposed Afib I don't know... Without calipers and a longer tracing, it looks more like some kind of block at first glance, the irregularity is too regular. Even if it is Afib it certainly is not a classic looking Afib. I'm going to see if I can find a better one unless someone else can first. - Dan D. Ric 01:30, 25 March 2007 (UTC)

Holy cow. Looking again at the larger image. This is most definitely NOT a tracing of Afib! The r-r intervals, except for the missing beats, are EXACTLY regular. I hope whoever decided this is Afib is never my cardiologist. The image should be removed till a real example of Afib is found. I'd do/say more except it's time for me to go to work. -- Dan D. Ric 01:39, 25 March 2007 (UTC)
The tracing appears to be atrial flutter with variable block. The rate is 150 with occasional dropped beats - the classic rate for atrial flutter is 150. I can convince myself of the sawtooth waveform as well. The morphology of a.fib / a.flutter is different, but the treatment is essentially the same. Dlodge 14:11, 25 March 2007 (UTC)

I'm glad to see someone else looking at this but I don't agree. Having only one lead to look at is a hindrance (as is me being out of practice since I haven't worked in cardiology for 3-4 years) but I'm not sure about a flutter, I don't see the sawtooth. How about some kind of accelerated junctional or junctional tach? Some of those QRS complexes look to have a retrograde P. Whatever it is, it is certainly not a good example of either Afib or flutter. - Dan D. Ric 15:14, 25 March 2007 (UTC)

Certainly a somewhat regular ventricular response. Atrial rhythm is unclear. Either atrial fibrillation with regular noise (electrical or mechanical artifact) or an atypical flutter with noise. I agree that the regular ventricular response makes things confusing. Someone's certainly got a better image, right? Ksheka 13:22, 11 May 2007 (UTC)


How about this image instead of the one currently in the Electrocardiogram section? I think it is a more typical atrial fibrillation albeit a bit slow. This is a 103 year old female with CHF and history of a-fib with RVR, on Digoxin, Diltiazem, Metoprolol, Furosemide and Potassium. Note the variations in the R-R and the numerous P-waves. A-fib.png

Dan D. Ric (talk) 16:14, 27 March 2009 (UTC)

ECG of atrial fibrillation (top) and sinus rhythm (bottom). The purple arrow indicates a P wave, which is lost in atrial fibrillation.

Here's the figure from the article. Comparing the nominal AF trace (upper) with the NSR trace (lower), one could also interpret the difference as extra beats in the upper trace, rather than missing beats. Also, there seems to be a diversity of AF and perhaps some patients may only appear to be close to NSR with regard to R-R, but not quite. It might be helpful if someone knew of an article that discusses the diversity of AF ECG's. --Bob K31416 (talk) 18:11, 27 March 2009 (UTC)

Just looking at the spacing of the QRS's, the first thing I would think is "Wenckebach," but whatever is going on in the baseline is too noisy to really tell. I think I may be seeing some P-R interval lengthening but it's too hard to pick out the P-waves in all that jumble. Dan D. Ric (talk) 23:02, 27 March 2009 (UTC)
First of all, don't p waves refer to the element of an ECG that corresponds to a coordinated contraction of the atria, not quivering, as appears to be happening in the AF ECG.
Secondly, how can you see a lengthening of the P-R interval (Wenckebach) if there aren't any p waves, much less a P-R interval? --Bob K31416 (talk) 14:17, 28 March 2009 (UTC)

Well, generally there are P-waves in A-fib, they just aren't all conducted to the ventricles. In a 2:1 or 3:1 flutter, which is a type of A-fib, only every other or every third P-wave is conducted and the rest blocked. Secondly, I don't believe the tracing currently in the article is A-fib anyway. There are what I believe to be P-waves but it is too hard to pick them out of the surrounding noise to be certain.

Anyway, the point is, is the one I uploaded a better example then what we have now? I'd like to hear some more opinions. Dan D. Ric (talk) 16:10, 28 March 2009 (UTC)

Here's an excerpt from an AHA web page titled Atrial Fibrillation (for Professionals), "As a result, there is no contraction of the atria as a whole. Since there is no uniform atrial depolarization, there is no P wave. " --Bob K31416 (talk) 17:43, 28 March 2009 (UTC)

Thyroxine[edit]

http://archinte.ama-assn.org/cgi/content/abstract/167/9/928?etoc - thyroxine levels are independently associated with presence of AF, even when asymptomatic and in normal TSH. JFW | T@lk 08:30, 15 May 2007 (UTC)

Over 75[edit]

doi:10.1016/S0140-6736(07)61233-1 - over 75 some are concerned re bleeding risk. This study seems to put that to rest - it compares aspirin to warfarin in a non-randomised fashion (can't randomise for weekly INR checks) and found a 50% relative and 2% absolute risk reduction. JFW | T@lk 09:35, 12 August 2007 (UTC)

Copyediting[edit]

I'm doing a bit of a copyedit to the article. In particular, I'd like to get rid of any headers in level 4 or over (as per the WP:MOS). I've moved some material to relevant sections (e.g. "screening" is now a dedicated section). I've started referencing much content to the ACC/AHA/ESC 2001 guideline. We also have the NICE guideline which definitely needs to be mentioned too. JFW | T@lk 19:17, 29 August 2007 (UTC)

I have been unable to completely eliminate use of level 4 headers. Some more content can probably be referenced to the ACC/AHA/ESC guideline. I will see if I can find this out in due course. JFW | T@lk 22:09, 29 August 2007 (UTC)

Organization of treatment section[edit]

I think the treatment section of the atrial fibrillation might benefit from different organization. What about:

6.1 Rate control versus rhythm control
6.2 Rate control
6.2.1 Acute rate control
6.2.2 Chronic rate control
6.3 Rhythm control
6.3.1 Conversion to sinus rhythm
6.3.2 Maintenance of sinus rhythm
6.3.2.1 Medications
6.3.2.2 Radiofrequency ablation
6.3.2.3 Surgery

With this structure, it reveals that we do not discuss acute therapy and also that we are not distinguishing between conversion to and maintenance of sinus rhythm.Badgettrg 14:58, 6 September 2007 (UTC)

I will agree to any organisation that avoids the need for deep headers. Acute therapy may warrant a separate section (is there any evidence?) but I feel we have quite a lot of information on rate vs rhythm. I thought those agents that converted to sinus also maintained sinus, or am I being ignorant? JFW | T@lk 19:12, 6 September 2007 (UTC)
A little while ago I rearranged the structure of the article to be slightly more straightforward. Today you changed it back without discussion. Why is that? JFW | T@lk 20:46, 6 September 2007 (UTC)
Which part?Badgettrg 20:55, 6 September 2007 (UTC)
I'm mainly referring to the reintroduction of level 5 headers, which I will not support on grounds of readability. I have removed them now, and agree with other modifications you've made. Never mind.
Are you aware of any cultural references and QOL studies in AF? I have identified American Journal of Medicine 2006;119(5):448.e1-448.e19. JFW | T@lk 12:00, 7 September 2007 (UTC)
cultural references and QOL studies in AF -> do not know of any
I still have some trouble with the treatment section. For example, the paragraph 'In refractory cases, where none of the above drugs are sufficient' being in the rate control section and not having a section titled 'Rate control versus rhythm control'. I think you are wanting to organized based on available treatment modalities, whereas I prefer to organize around the clinical settings likely to arise - even though it means discussing a treatment in more than one section.
The pros/cons of level 5 headers is interesting; so the discussion does not get lost, I am continuing it below in its own section.Badgettrg 03:47, 9 September 2007 (UTC)

Level 5 headers[edit]

Personally, I do not mind the version with level 5 headers if there are concepts that really nest that deep. I could not find any WP recommendations against using level 5 headers - though I may have missed something - I checked Wikipedia:Manual of Style (headings). Regardless, in searching for WP policy on this, I found an interesting technical compromise - Help:Section: Limiting the TOC. My reasons for using headers as needed are:

  1. A number of times, I have found myself and other authors, putting too much detail about a subtopic in page, not realizing that a page already exists that is devoted to the topic (see cluster of topics on low back pain). This duplication of content then snowballs to where we have two large texts in parallel on the same topic. It is time-consuming and nearly impossible to harmonize and maintain the separate sections.
  2. When I have watched students and residents reading Internet pages, I am impressed how often the answer is in front of them but they do not see it - in part because there the blocks of text are too large, or the text they want is not represented in the TOC. Two studies that somewhat support the advantages of sections are Answering physicians' clinical questions: obstacles and potential solutions and Using structured medical information to improve students' problem-solving performance. Unfortunately, these articles do not address how much nesting can occur before text and TOCs become unusable.

Two avoid these two problems, I would use 5 sections if they are needed. However, determining 'need' is difficutl. If your not liking level 5 is the effect on the TOC, what about Help:Section: Limiting the TOC? So we would use {{TOClimit|limit=4}} or even {{TOClimit|limit=3}}. While a second alternative is to use bold text in front of paragraphs, this precludes using tags such as {{main|warfarin}} to visually alert in readers and authors that more detailed content is available.

What about the following which I think avoids level 5 headers. This could be done with {{TOClimit|limit=4}} or even {{TOClimit|limit=3}}:

6.1 Rate control versus rhythm control
6.2 Rate control
6.2.1 Acute rate control
(allows space for discussion that we currently do not have about using beta and ca blockers intravenously)
6.2.2 Chronic rate control
6.3 Rhythm control
6.3.1 Conversion to sinus rhythm
6.3.1.1 Medications
6.3.2.1 DC Cardioversion
6.3.2 Maintenance of sinus rhythm
6.3.2.1 Medications
6.3.2.2 Radiofrequency ablation
6.3.2.3 Surgery

I think this is a difficult topic to organize, yet this page is very good. When I look at UpToDate's content, it is rather disorganized with 21 chapters that have a-fib in the title.Badgettrg 03:47, 9 September 2007 (UTC)

I think I can agree with the outline. An alternative for {{TOClimit}} is using the semicolon method. Prefacing a header with a ";" (instead of surrounding it with "=" signs) generates a bolded heading that doesn't show up in the TOC. JFW | T@lk 20:52, 15 September 2007 (UTC)
For your consideration (From my presentation on the topic a couple months ago):
1. Epidemiology
2. Etiology
3. Classification
4. Sequelae
5. Pathophysiology
6. Mechanism
7. Evaluation
7.1 Minimal evaluation
7.2 Extended evaluation
8. Management
8.1 Anticoagulation
8.2 Rate vs. Rhythm control
8.2.1 Rate control
8.2.2 Cardioversion
8.2.3 Maintenance of sinus rhythm
Ksheka 14:00, 17 September 2007 (UTC)
Okay. I decided to be bold and changed the organization of the entire article based on my outline above. We'll still need 4-level-deep headers, but the organization works better in general. (Though I wasn't sure where to put History. :-)) FYI, I think there is still a lot to be written in many of the sections. Ksheka 02:20, 18 September 2007 (UTC)

Sequelae/Natural History[edit]

For what it's worth, I think we're missing out without a sequelae (or natural history) section of the article. Stroke is one thing to be mentioned. Tachycardia-induced cardiomyopathy is another. And of course death. It's all in the article (somewhat spread out), but casual readers may look for a section like that. Ksheka 12:06, 19 September 2007 (UTC)

Clinical medicine/Template for medical conditions[edit]

  1. Going by Template for medical conditions, ok to move Classification to the first section?
Sounds like Classification should go before Diagnosis. Not sure if it should go before Signs and symptoms. First section is certainly reasonable for me. Ksheka 00:42, 20 September 2007 (UTC)
  1. Very good point about missing natural history. I think I would label this 'complications' and go after prognosis is the standard order. To me this is so important, we should lobby to get it added to Template for medical conditions so other topics benefit from this structure.
  2. Ok if I insert a section 6.6.6 for "Determining risk of stroke"?

Badgettrg 12:59, 19 September 2007 (UTC)

I was thinking of a new 6.0 - Natural history, with stroke being 6.1 and risk of stroke 6.1.1. Ksheka 13:40, 19 September 2007 (UTC)
This brings up a recurring conundrum for me: when a treatment decision is tightly bound to a prognostic calculation, where do you put the prediction rule for the calculation? In the prognosis section, or the treatment section, or the complications section, or the natural hx section? This one stumps me.Badgettrg
Prognosis and natural history generally mean the same thing. I would put risk calculations in with them. That also means putting natural history/prognosis earlier in the article than treatment. (between Pathophysiology and Treatment in the current article) Ksheka 00:39, 20 September 2007 (UTC)
Also, are we so bound by Template for medical conditions, or it just a gentle suggestion? I haven't been too active lately in wikipedia and wasn't sure if this was something that all medical articles were being refactored into. Ksheka 16:24, 19 September 2007 (UTC)
Doubt we are bound, but I do not know. In some ways (having classification early) it helps much, but in others (prognosis/complications) it is not helpful to me in its current form.Badgettrg
There is some flexibility on order. FYI, Wikipedia:Manual of Style (medicine-related articles) has superseded Template for medical conditions, and provides some guidance on these issues, under the header "Diseases/disorders/syndromes". --Arcadian 01:53, 20 September 2007 (UTC)

Some sources[edit]

Prevalence of Diagnosed Atrial Fibrillation in Adults may be a better source for the "2.3 million" statistic. The mortality figure is well supported with PMID 11978585. I will add these sources in due course (i.e. when I've scoured the fulltext). JFW | T@lk 16:47, 24 September 2007 (UTC)

I found this useful. JFW | T@lk 16:49, 24 September 2007 (UTC)
I noticed a lot of references pointing to the guidelines. As you noticed, at least one of the references in the guidelines (to statistics) doesn't make sense. Probably better to cite the actual papers rather than the guidelines, right? Ksheka 19:50, 24 September 2007 (UTC)
I refer to guidelines when there is a cornucopia of papers but little agreement, and where there are various approaches for treatment and priorities are needed. If the guidelines are based on systematic reviews, they are very useful indeed. Now that we have found a rotten apple, a newer reference is obviously needed. JFW | T@lk 21:31, 16 October 2007 (UTC)

LIFE EXPECTANCY[edit]

Could someone add a section to this article about life expectancies for sufferers? Thanks! —Preceding unsigned comment added by 124.171.95.93 (talk) 07:19, 30 September 2007 (UTC)

I'm not quite sure if that data is available. It is going to be a number with a very wide margin of confidence, rendering it practically meaningless. Some people live with AF for decades, and others have recurrent debilitating strokes. JFW | T@lk 21:31, 16 October 2007 (UTC)

Assessment[edit]

I don't usually rate things above "B" for the WPMED project, but it seems to me that this might easily meet the Good Article criteria. Perhaps someone should look up the criteria and see whether it seems likely to survive a nomination. WhatamIdoing (talk) 23:32, 19 January 2008 (UTC)

Catheter ablation better[edit]

http://archinte.ama-assn.org/cgi/content/abstract/168/6/581 catheter ablation (CPVA) is better than rhythm control. JFW | T@lk 02:59, 25 March 2008 (UTC)

"Main article: " form needed?[edit]

After a number of section headings there is a reference to Main article. For example,

    Electrocardiogram
         Main article: Electrocardiogram
    Atrial fibrillation is diagnosed on an electrocardiogram (ECG), an investigation ...

In the above excerpt, "Main article: Electrocardiogram" doesn't seem to be needed since there is a link to the electrocardiogram wiki in that section. Perhaps it should be deleted along with similar instances of "Main article: xxxxxx" in other sections where the link is provided to their respective xxxxxx wikis. I checked that all sections have appropriate links in their respective text. ( I added a link in the one case where there wasn't one in the section's text.) Bob K31416 (talk) 03:24, 19 May 2008 (UTC)

The {{Main}} template should really only be used if it is a subarticle of the present one. JFW | T@lk 05:34, 20 May 2008 (UTC)
JFW, Thanks for the info. After reading your comment and looking at {{Main}} and Wikipedia:Summary style it does appear that the {{Main}} template was inappropriately used since e.g. the article Electrocardiogram did not grow out of the present article Atrial fibrillation. For those interested, this excerpt from Wikipedia:Summary style gives more useful details of the proper use of the {{Main}} template,
"Wikipedia articles tend to grow in a way which lends itself to the natural creation of new articles. The text of any article consists of a sequence of related but distinct subtopics. When there is enough text in a given subtopic to merit its own article, that text can be summarized from the present article and a link provided to the more detailed article."
So I'll delete instances of the form "Main article: xxxxxx" that refer to wikis that were started before the present article and thus weren't originally in the present article. I'll look to see if the other "Main article" references were originally in the present article.
However, even if they originated in the present article, it still doesn't seem useful to use the {{Main}} template if there is a link to the spinoff article in the section's text. I'd appreciate any more of your thoughts. Bob K31416 (talk) 15:10, 20 May 2008 (UTC)
I investigated whether any of the "Main article" references were originally in the present article. I found that almost all of the "Main article: xxxxxx" entries were made on 24Sep2007 by Ksheka. Also, I looked at the first instance of the referenced articles in their respective histories and the corresponding state of the AF article at that time for many of the referenced articles. Most likely all of the referenced articles did not first appear in the present article on AF so, with my previous remarks in mind, there doesn't seem to be any reason for keeping the "Main article: xxxxxx" entries. Bob K31416 (talk) 22:15, 20 May 2008 (UTC)

Classification[edit]

It appears to be difficult to achieve a well organized classification system for AF. This may be due to: the diversity of episode timing and termination characteristics; the diversity of category names and their definitions that have appeared in the literature; and the seemingly inevitable overlap of categories. Even the AHA/ACC/ESC 2006 Guidelines appears to have trouble with coherence in this regard. The part of those Guidelines that seems to have the simplest and most systematic attempt at classification is Fig. 3. From that figure comes the following classification system:

  • First detected
  • Paroxysmal - self-terminating, lasting less than 7 days
  • Persistent - not self-terminating, lasting more than 7 days and terminated by intervention
  • Permanent - not self-terminating, lasting continuously long-term (e.g. for a year or more) and termination by intervention either failed or not attempted

Additional categories come from the rest of the Guidelines' classification section:

  • LAF
  • nonvalvular

Currently, the AF wiki's interpretation of the Guidelines' classification system lumps together most of the major categories (paroxysmal, persistent, and permanent) into the one category "Recurrent atrial fibrillation". Furthermore, "Recurrent..." is too large a category compared to the "First detected..." category. So it seems reasonable to use the system in the Guidelines' Fig. 3 to replace the "Recurrent..." category in the AF wiki with the categories Paroxysmal, Persistent, and Permanent.

Also, in addition to the LAF category in the AF wiki, the category "Nonvalvular AF" should be mentioned in the Classification section since it is referred to later in the AF wiki, it is in the classification section of the Guidelines, and it appears in many other journal articles.

Finally, the use of the term "chronic" can be a source of confusion. It has been used to differentiate long-term episodes from short-term episodes but this can be confusing. The reason for the confusion is that one might reasonably think that the term "chronic" would apply to having short-term episodes frequently, over and over again, without an end to the paroxysmal AF.

Bob K31416 (talk) 01:49, 26 May 2008 (UTC)

Anticoagulation and Lone Atrial Fibrillation (LAF)[edit]

The first line of the section on Anticoagulation is:

“Patients with atrial fibrillation, even lone atrial fibrillation without other evidence of heart disease, are at increased risk of stroke during long term follow up.[1]

One has to be careful interpreting the cited reference regarding LAF. It’s not clear that any of the patients who had strokes in the study were in the LAF category just before they had their stroke. In fact, they probably weren’t in the LAF category just before their stroke since on page 3453 of the article was the following statement,

“With total cardiovascular disease developing in more than 40% of the lone AF subjects at risk in this study, one would expect that underlying heart disease was present at the time of AF diagnosis, although clinically not observed nor unexpected in this group of older individuals.”

In other words, 40% of the subjects in the study who were supposedly in the LAF category at the beginning of the study either had or developed cardiovascular disease that moved them out of the LAF category. Furthermore, most if not all of the subjects who had a stroke were probably no longer in the LAF category just before the stroke but were among the 40% who had cardiovascular disease. Support for this assertion is a more current study of LAF which stated,

“Risk for stroke or transient ischemic attack was similar to the expected population risk during the initial 25 years of follow-up but increased thereafter (P=0.004), although CIs were wide. All patients who had a cerebrovascular event had developed > or = 1 risk factor for thromboembolism.”[2]

Thus, I feel that the phrase "even lone atrial fibrillation without other evidence of heart disease" should be deleted along with its associated reference, and the rest of the sentence should be modified to exclude LAF from the general assertion.


  1. ^ Brand FN, Abbott RD, Kannel WB, Wolf PA (1985). "Characteristics and prognosis of lone atrial fibrillation. 30-year follow-up in the Framingham Study". JAMA 254 (24): 3449–53. doi:10.1001/jama.254.24.3449. PMID 4068186. 
  2. ^ Jahangir A, Lee V, Friedman PA, Trusty JM, Hodge DO, Kopecky SL, Packer DL, Hammill SC, Shen WK, Gersh BJ (2007). "Long-term progression and outcomes with aging in patients with lone atrial fibrillation: a 30-year follow-up study". Circulation 115 (24): 3050–6. doi:10.1161/CIRCULATIONAHA.106.644484. PMID 17548732. 

Bob K31416 (talk) 04:19, 4 June 2008 (UTC)

Autonomic Nervous System and AF[edit]

ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation Sections 6.1.6, 8.3.1.1, 8.3.2, 9.1.2
Autonomic nerve activity and atrial fibrillation
--Bob K31416 (talk) 18:05, 8 July 2008 (UTC)

Recent deletions of advertising[edit]

FHCPinehurst, Recent deletions of your contributions were due to advertising. The contributions were in a style that promoted a procedure, a doctor and a hospital. Please note the style of the rest of this wiki and try to conform. For example, doctors and hospitals aren't mentioned unless they are recognized pioneers, such as Cox and possibly Saltman, and it is the goal to describe procedures objectively in a way that doesn't try to influence readers to use them. Material in this wiki is not trying to sell readers on any product or service and it is the goal to present the material with a neutral point of view (WP:NPOV). Thank you. --Bob K31416 (talk) 19:06, 5 February 2009 (UTC)

However, I do agree that the basic info about the procedure should be in the wiki, without the advertising style, so I modified your contribution and added it. --Bob K31416 (talk) 20:07, 5 February 2009 (UTC)

I can understand not wanting any advertising, but why do you allow the link to Robert Wood Johnson University Hospital via "Minimally Invasive Surgical (Endoscopic) Procedures"? How is that an exception?--FHCPinehurst (talk) 20:48, 5 February 2009 (UTC)

Thank you. I noticed that link too during my editing today and it is something to consider for possible deletion. I suspect that others have considered its informative value and decided to keep it, but I'm not sure of this. Please note that you are not being singled out and advertising has been routinely deleted in the past. Also note that I have since included the Ex-maze in the wiki without the advertising style. --Bob K31416 (talk) 21:46, 5 February 2009 (UTC)
The link provides some nice pictures, which may aid people's understanding. Nonetheless, it does smack of aducation rather than education. Another thought - just to provide a more global perspective - is this procedure performed anywhere outside the US? Mattopaedia (talk) 12:29, 8 February 2009 (UTC)
Re RWJ hospital link with useful diagrams- For the moment, I reduced the in-text link to a less prominent inline citation. Perhaps it can be replaced by a journal article that has similar diagrams for the minimaze. --Bob K31416 (talk) 13:41, 8 February 2009 (UTC)
I just added to a citation a link to the fulltext version of a reference that contains diagrams, although the RWJ diagrams have some additional info. So the RWJ has become more deletable. Something to think about. And perhaps the RWJ diagrams are in another journal article. --Bob K31416 (talk) 22:22, 8 February 2009 (UTC)

Risk assessment[edit]

Would this modification of the recently deleted section Prevention and Risk Assessment, be acceptable?

==Risk Assessment==
Even though one in four will develop atrial fibrillation in their lifetime, systematic studies of risk factors and prevention methods have been lacking. Patient features most closely related to future AF included age, sex, body-mass index, systolic blood pressure, treatment for hypertension, electrocardiographic PR interval, clinically important cardiac murmur, and heart failure. Devised from those risk factors, the scoring system assigned, for example, more points with advancing age (according to different scales for men and women) and more points the younger patients are at diagnosis of heart failure or a clinically important murmur.[1]

--Bob K31416 (talk) 01:29, 1 March 2009 (UTC)

P.S. I wasn't the one who put in the Prevention and Risk Assessment section under an IP address. --Bob K31416 (talk) 01:38, 1 March 2009 (UTC)

Prevention and risk assessment -- not to remove[edit]

Though it cited authority, the following section was once removed by an esteemed and prolific medical editor.

An informative removal note seemed to overlook risk assessment, though it was the major subject of the section and has lately taken a major step forward, as stated and substantiated in the removed text.

Second, the removal note expressed an opinion that there are no measures available for reducing risk if AF. This opinion (unsourced, though coming from a doctor) turns a blind eye to sourced "... tantalizing observational evidence that patients on statins or ACE inhibitors or those with high intake of omega-3 fatty acids may be at reduced risk of developing AF."

This observational evidence is the best there is, whereas the opinion that no measures exist for risk reduction does not appear to have any support at all.

Making available the best evidence currently available, albeit imperfect, may serve public health and does very little harm.

—Preceding unsigned comment added by 69.3.11.111 (talk) 18:20, 1 March 2009 (UTC)

See above section on Talk page, Risk assessment, for a compromise. --Bob K31416 (talk) 18:27, 1 March 2009 (UTC)

Prevention and Risk Assessment[edit]

Even though one in four will develop atrial fibrillation in their lifetime, systematic studies of risk factors and prevention methods have been lacking.[2] Researchers for the Framingham Heart Study announced the first risk prevention tool in February, 2009.

In multivariate analyses, baseline patient features significantly and most closely related to future AF included age, sex, body-mass index, systolic blood pressure, treatment for hypertension, electrocardiographic PR interval, clinically important cardiac murmur, and heart failure. Devised from those risk factors, the scoring system assigned, for example, more points with advancing age (according to different scales for men and women) and more points the younger patients are at diagnosis of heart failure or a clinically important murmur.[3]

Risk prevention is of value despite the lack of extensive study of possible prevention methods, in light of the

... tantalizing observational evidence that patients on statins or ACE inhibitors or those with high intake of omega-3 fatty acids may be at reduced risk of developing AF. ... [4]

—Preceding unsigned comment added by 69.3.11.111 (talk) 18:20, 1 March 2009 (UTC)

My take on "prevention"[edit]

The new Framingham score is interesting, and perhaps we should discuss it as part of the "epidemiology" section. However, it would be silly to suggest that anyone is actively "preventing" AF specifically by treating the risk factors. Rather, hypertension is treated to prevent stroke and ischaemic heart disease, etc etc. As such, there are no preventative strategies for AF. JFW | T@lk 20:25, 1 March 2009 (UTC)

Your take is supported by the source too. Here's the rest of the context for the quote re "tantalizing", which I highlighted in bold, as I did points that are more negative.
Benjamin acknowledges that the AF-risk scores are currently likely to be more useful in a research setting than in clinical practice; there aren't any accepted treatments for preventing AF that have randomized, controlled trial support.
"We know a tremendous amount about how to prevent coronary heart disease. But the lifetime risk of atrial fib is about one in four, similar to the lifetime risk of heart failure, and we really know very little about how to prevent the onset of atrial fibrillation," she said.
On the other hand, there is tantalizing observational evidence that patients on statins or ACE inhibitors or those with high intake of omega-3 fatty acids may be at reduced risk of developing AF. It might be reasonable, then, to explore those possible treatments in primary-prevention trials, which traditionally are conducted first in high-risk populations, Benjamin notes.
Here's what the editor wrote.
Risk prevention is of value despite the lack of extensive study of possible prevention methods, in light of the
... tantalizing observational evidence that patients on statins or ACE inhibitors or those with high intake of omega-3 fatty acids may be at reduced risk of developing AF. ... [5]
It looks like the editor misinterpreted the source when the editor made the statement, "Risk prevention is of value... ". But like you suggested, there may be something useful to add to the Epidemiology section that doesn't involve prevention. I don't think the "compromise" suggestion that I hurriedly made above for a separate section, is suitable for the Epidemiology section in its present form. But there may be something on risk assessment that might be added to the Epidemiology section that would improve the article. --Bob K31416 (talk) 03:33, 2 March 2009 (UTC)

Speaking from the standpoint of a patient with long-standing paroxysmal AF, I can say that my current drug, propafenone (Rythmol SR)325mg has done the best job of preventing PACs; and when I did have an episode of AF, I converted to sinus rythm spontaneously (13 hours) and did not require cardioversion, as I had when I was taking acebutelol. My cardiologist had me on sotalol for a brief period, but the side effects and safety profile were unsuitable. Switching from beta blocker to propafenone has increased my resting heart rate from the high 70's to the high 80's, but my aerobic exercise capacity has improved with no increase in blood pressure. —Preceding unsigned comment added by Brucekdixon (talkcontribs) 16:02, 18 August 2009 (UTC)

The trouble with digoxin[edit]

Temporarily removed:

Recent research questions the use of digoxin for AF. Increased mortality and faster transition from paroxymal to permanent AF by increased intracellular Ca ion overload can be the result of digoxin.[1] [2][3][4][5]

The sources are interesting, but I still suspect this amounts to WP:SYNTH. No official guideline discourages the use of digoxin for the reasons that it might induce permanent AF or increase mortality. The papers suggesting a risk of permanent AF are observational studies with indirect outcomes, and really do not prove much at all. The paper suggesting increased mortality looked at exactly 22 patients - not quite enough at all to draw any solid conclusions.

The British guidelines already discourage first-line use of digoxin apart from in the sedentary elderly. In the emergency setting, it is often the only suitable anti-arrhythmic if the patient is already borderline hypotensive and beta-blockers and calcium channel blockers would be unsuitable. JFW | T@lk 08:12, 17 April 2009 (UTC)

Why not mention those guilines and the reason as many physicians routinely prescribe digoxin as a first line drug for otherwise healthy even young individuals? —Preceding unsigned comment added by 85.227.199.27 (talk) 13:30, 17 April 2009 (UTC)
The paper from Uppsala [6] says:
Conclusion The results suggest that long-term therapy with digoxin is an independent risk factor for death in patients with AF without CHF.
The group of patients with AF and no CHF had a much larger cohort, 60,764, and you cannot just ignore their result. Digoxin cannot be put in the same group as beta- and calcium-blockers without any reservations. —Preceding unsigned comment added by 85.227.199.27 (talk) 18:45, 20 April 2009 (UTC)
From the comments by JFW and 85.227.199.27, perhaps there should be something added to the article re JFW's remark, "The British guidelines already discourage first-line use of digoxin apart from in the sedentary elderly." --Bob K31416 (talk) 02:01, 25 April 2009 (UTC)
Here's a link to the British guidelines. --Bob K31416 (talk) 13:40, 25 April 2009 (UTC)

What about: Digoxin should be restricted to patients with permanent AF and CHF when a beta-blocker or calcium channel-blocker cannot be used. —Preceding unsigned comment added by 85.227.141.186 (talk) 08:16, 3 May 2009 (UTC)

From what I saw in the British Guidelines (i.e. NICE), CHF wasn't mentioned with regard to Digoxin. Use of Digoxin alone for permanent AF was limited to sedentary people when BBs and CCBs were contraindicated. However, when BBs or CCBs alone were indicated but inadequate, Digoxin in combination with a BB or a CCB was recommended. See p. 61. --Bob K31416 (talk) 21:39, 3 May 2009 (UTC)

So what is your suggestion? Would this solve your objections: Digoxin should be restricted to patients with permanent AF when a beta-blocker or calcium channel-blocker cannot be used. —Preceding unsigned comment added by GunnarK (talkcontribs) 04:15, 4 May 2009 (UTC)

I would suggest: "- has limited use" so that the line in the article would be,
I would also add the British guidelines citation to the AHA/ACC/ESC guidelines citation at the beginning of the Rate control section.
"Atrial fibrillation: national clinical guideline for management in primary and secondary care" (PDF), National Collaborating Centre for Chronic Conditions, London: Royal College of Physicians, 2006, retrieved 2009-05-05 
P.S. Your last suggestion is not quite correct since digoxin can be used in combination with BBs and CCBs too. Also, you didn't mention the sedentary requirement. And in the AHA/ACC/ESC Guidelines, digoxin is used in other situations too. (BTW, they did mention HF there.) I decided to bypass these details since mentioning them would give undue weight to digoxin compared to BBs and CCBs.
--Bob K31416 (talk) 14:57, 5 May 2009 (UTC)
I just put the above suggestion in the article. --Bob K31416 (talk) 00:14, 9 May 2009 (UTC)

Thank you! I have been busy with other things. —Preceding unsigned comment added by GunnarK (talkcontribs) 08:57, 13 May 2009 (UTC)

OMIM[edit]

OMIM lists eight loci for familial AF (here). Do we need to link to all of them? JFW | T@lk 08:18, 22 August 2010 (UTC)

Would this link be what you want? (Unfortunately it has #9 which I wasn't able to remove.) --Bob K31416 (talk) 18:36, 22 August 2010 (UTC)


Sodium Channel Blockers[edit]

A relatively new class of anti-arrhytmic medications called sodium channel blockers are used to treat atrial fibrillation. These seem to be somewhat toxic and are probably used when calcium channel blockers and beta blockers are ineffective. I think the best known sodium channel blocker for A-Fib is Propafenone, brand name Rhythmol. There is a Wikipedia article on Propafenone. I don't believe the article currently mentions this method of treatment. It's probably worthy of mention. 68.127.237.37 (talk) 21:57, 6 November 2010 (UTC)

New afib management[edit]

Circulation [7] Doc James (talk · contribs · email) 13:34, 21 December 2010 (UTC)

Unclear sentence[edit]

"The level of increased risk of stroke depends on the number of additional risk factors." What risk factors? Are they for a certain kind of strokes? Imagine Reason (talk) 06:11, 11 October 2011 (UTC)

Another unclear sentence[edit]

"A minimal evaluation should be performed in all individuals with AF." Sentence has two meanings. Will edit to reflect specifically what is intended. FeatherPluma (talk) 01:25, 6 November 2011 (UTC)

INR[edit]

I did not see a reference to the "INR" in this article, but I believe that this is assessed in sufferers of atrial fibrilation. As I am no expert on this subject (I shall confess that I do not even know what "INR" stands for!) I do not wish to edit the article. ACEOREVIVED (talk) 00:27, 14 March 2012 (UTC)

It is only used if someone with atrial fibrillation is being treated with warfarin or another vitamin K antagonist. INR is used to determine the correct dose. JFW | T@lk 22:17, 6 March 2013 (UTC)

Cognitive impairment[edit]

Meta-analysis: here. JFW | T@lk 22:17, 6 March 2013 (UTC)

This also: doi:10.1093/qjmed/hct129 (from QJM). JFW | T@lk 16:42, 8 September 2013 (UTC)

Lower target INR in the elderly[edit]

DocElisa (talk · contribs) suggested that we mention lower target INR in the elderly in view of a "redoubtable" risk of bleeding. This is supported with a primary research study, and also with the 2010 ESC guideline. The latter however says:

The claim is therefore not supported by the most important reference. JFW | T@lk 21:42, 6 April 2013 (UTC)

When I talk about geriatric patients I mean patients with ages >75 years old not >65. These patients have many risk factors like hypertension, they fall much more than young persons, they take most of the time anti-inflamatory drugs. In geriatrics an INR between 1.8 and 2.5 is enough to protect them. Most of these patients have chronic AF. The problem will be different if we face an intermittent AF. I think that this section can be expanded to explain better the problem. I´m always afraid when I see general clinicians treating 85 years old patients with warfarine with INR around 3 just because they have a chronic AF. Doc Elisa 11:13, 11 April 2013 (UTC)
I don't disagree in principle, but the source contradicts what you were trying to say. JFW | T@lk 21:35, 14 April 2013 (UTC)

tPA antigen[edit]

tPA antigen levels predict cardiac/embolic events and death: doi:10.1111/jth.12213. Not for inclusion, but may become useful in stratifying risk. JFW | T@lk 12:46, 9 April 2013 (UTC)

WP:MEDRS[edit]

The use of WP:MEDRS to revert recent edits, while done in good faith, seems incorrect. First, this page has plenty of existing references to primary research; second, the secondary sources use to replace the original studies I cited do not cover the same content about the accuracy of the physical exam.

WP:MEDRS says primary sources ok if secondary sources do not cover the content. However, I only see WP:MEDRS used to remove primary sources.

How is arbitration arranged over disputed edits? Thanks. - Robert Badgett 05:14, 18 November 2013 (UTC)

We use secondary sources to determine how much weight to give something. Typically in a main article we expect secondary sources. If you can get consensus than you can use it. Doc James (talk · contribs · email) (if I write on your page reply on mine) 05:28, 18 November 2013 (UTC)

I ask your advice about Medical algorithm for treatment of atrial fibrillation[edit]

I have placed this medical algorithm for treatment of atrial fibrillation in the Russian Wikipedia (Atrial fibrillation ru:Фибрилляция предсердий) — see the illustration on the right.

I want to ask. Maybe, this illustration should be placed into Atrial fibrillation also. Or will it be wrong? How do you think?

--Владимир Паронджанов (talk) 10:49, 11 April 2014 (UTC)


  1. ^ Steve Stiles Risk-Prediction Model for Future Atrial Fib Deepens Hopes for Primary Prevention from Heartwire — a professional news service of WebMD February 27, 2009 (Framingham, Massachusetts) http://www.medscape.com/viewarticle/588887
  2. ^ Steve Stiles Risk-Prediction Model for Future Atrial Fib Deepens Hopes for Primary Prevention from Heartwire — a professional news service of WebMD February 27, 2009 (Framingham, Massachusetts) http://www.medscape.com/viewarticle/588887
  3. ^ Steve Stiles Risk-Prediction Model for Future Atrial Fib Deepens Hopes for Primary Prevention from Heartwire — a professional news service of WebMD February 27, 2009 (Framingham, Massachusetts) http://www.medscape.com/viewarticle/588887
  4. ^ Steve Stiles Risk-Prediction Model for Future Atrial Fib Deepens Hopes for Primary Prevention from Heartwire — a professional news service of WebMD February 27, 2009 (Framingham, Massachusetts) http://www.medscape.com/viewarticle/588887
  5. ^ Steve Stiles Risk-Prediction Model for Future Atrial Fib Deepens Hopes for Primary Prevention from Heartwire — a professional news service of WebMD February 27, 2009 (Framingham, Massachusetts) http://www.medscape.com/viewarticle/588887
  6. ^ Поликлиническая терапия. Учебник. — Под ред. проф. И. Л. Давыдкина, проф. Ю. В. Щукина. — М.: ГЭОТАР-Медиа, 2013. — 688c. — ISBN 978-5-9704-2396-7 — C. 114-115.