Atrial Fib with Rapid Ventricular Rate

Working of the heart:

To easily identify atrial fibrillation with RVR, it is vital to understand the working of the heart. The atrium or atria (plural) is the upper chamber of the heart, bigger in size compared to the lower chambers known as the ventricles. The atria function by gathering blood as it flows into the heart and shrinking to forward the blood into the ventricles. At the very moment, the smaller ventricle must shrink to forward the blood to all parts of the body. This rhythm of blood flow creates a heart signature voice referred to as the Sinus rhythm. It is important that the sinus rhythm is synchronized so that the atrium does not send blood into the ventricle out of cue. To achieve this, an electric signal is generated to ensure the atrium contracts. When this signal short circuits (bypasses) the atrium, atrial fibrillation with RVR occurs, and the atrium is seen to vibrate just like jelly on a flat surface.

Atrial fib with RVR refers to atrial fibrillation with rapid ventricular rate. Usually the heart is like clockwork, the top (collecting) chambers beat then the bottom (main pumping) chambers sense this and also beat, and so on, in a nice regular fashion just like a clock ticking second after second. Usually the heart beats at about 60-80 beats per minute.

In atrial fibrillation the top chamber basically goes crazy often firing off over 400 beats per minute! Atrial fibrillation with RVR (Rapid Ventricular Response) is a heart condition caused by irregular electrical activity that results in irregular contractions of the 2 top heart chambers fibrillating. This means the heart (atriums), shakes with a rapid tremulous movement or makes fine irregular twitching movements, generally referred to as fibrillating causing little control in the heart output of blood by the heart but the lower chambers called the ventricles take over.

These bottom chambers don’t allow all those impulses through but it does let every second or third one through. This can give a heart rate of 100-180 beats per minute at rest, still too many beats, known as Afib with RVR, leading to symptoms and problems with heart function. Afib does not necessarily lead to Afib with RVR however, Afib can be rate controlled, sometimes naturally, sometimes using medications and sometimes requiring procedures as discussed below.

In most people with AFib although symptoms can sometimes be unpleasant it is generally not harmful as long as the afib is controlled, meaning the heart in the afib rhythm with the pulse under 100. The main concern is stroke, but that can be treated with the use of blood thinning medications in people at risk. In Afib with RVR, basically the heart is beating too fast. Of course palpitations are the most common symptom. Other symptoms of AFib with RVR may include dizziness, lack of energy, exercise intolerance and shortness of breath. If Afib with RVR goes on for too long then this may result in heart failure and of course worsening of existing heart failure. Control of the heart rate in patients with Afib with RVR often causes these symptoms to improve, again meaning the HR is under 100 with the heart rhythm in afib.

A major indication of atrial fibrillation with RVR is a very rapid heartbeat rate, although some patients are known to have the condition without showing symptoms. Atrial fibrillation with RVR may occur when cardiac muscle cells overcome their intrinsic pacemaker’s signals and fire rapidly differently from their normal pattern spreading the abnormal activity to the ventricles. The rapid heart rate can strain the heart, developing a situation referred to as Tachycardia (meaning a pulse greater than 100). Atrial fibrillation with RVR can be detected from the various symptoms though it is important to remember that some patients have experienced the condition without symptoms.

Symptoms:

Some of the symptoms of this disease include heart palpitations (described as unnoticed skipped beats or skipped beats noticed from experienced dizziness or difficulty in breathing), shortness of breath when lying flat (orthopnea), shortness of breath (dyspnea after exertion) sudden onset of short breath during the night (also called paroxysmal nocturnal dyspnea) and gradual swelling of lower extremities. As a result of inadequate blood flow, some patients complain of light headedness and may feel like they are about to faint, a condition referred to as presyncope and may actually lose consciousness (syncope). Some patients experience respiratory distress that results in them appearing blue. A close examination of jugular veins usually reveals elevated pressure in some patients (jugular venous distention). When some patients are subjected to lung examinations, crackles and rales may be observed pointing to possible lung edema.

Importance of proper diagnosis:

A good diagnosis of the symptoms shown by patients is important to ascertain that the patient is suffering from atrial fibrillation with RVR.  This is because some forms or irregular and rapid heart rates, tachyarrhythmia, are dangerous and must be ruled out as they are life threatening – such as ventricular tachycardia. Some patients are usually placed on continuous cardio respiratory monitoring, but an electrocardiogram ECG is vital for correct diagnosis.

How is it diagnosed?

Simple, a typical 12 lead electrocardiogram (ECG). This test shows cardiac rhythms which atrial fibrillation is. Rhythms are made up of types of waves that the ECG shows which are P waves, QRS waves, T waves and U waves.

The QRS complexes should be narrow, to signify that they are being initiated by normal conduction of atrial electrical activity through the Intra-ventricular conduction system, or heart conduction system. Wide QRS complexes could point to ventricular tachycardia, although wide complexes may also be an indication of disease processes in the Intra-ventricular conduction system. The R-R internal will also likely be irregular. Meaning measuring from each R section of the QRS rhythm. It is also important to find out if there are triggering causes for the tachycardia which include dehydration, Hypovolemia – a decrease in blood volume, and more specifically decrease in blood plasma volume. You can go ahead to eliminate Acute coronary syndrome – which refers to any diseases that are directly attributed to the obstruction of coronary arteries.

WHAT IS THE TREATMENT:

A Shock

This is known as cardioversion and is used typically either when an immediate result is required or used when the Afib is of relatively recent onset or only intermittent, and so has more chance of staying in normal rhythm. In cardioversion a small shock is given using defibrillation pads. It is done under light anesthesia therefore it doesn’t hurt. The Afib may return however.

Rate Control Drugs

The biggest problem in Afib with RVR is too fast a heart rate. In a rhythm control strategy we use drugs such as beta-blockers to slow the heart rate down. These drugs typically will leave the patient in AF. For many people with AF it turns out that a rate control strategy is preferred as it is considered less risky than the rhythm control drugs used to get rid of the AF while being just as effective. In Afib with RVR rate control drugs can often slow the heart rate down fairly quickly and improve symptoms.

Rhythm Control Drugs

These medications are generally more powerful than the rate control drugs and attempt to convert the Afib back in to a normal rhythm. They are often given after a shock treatment to try and help the heart stay in normal rhythm. These drugs are also commonly used in hospitalized Afib with RVR patients. The problem with these drugs is that they may have side effects and associated risks. Many patients simply cannot tolerate Afib even if the rate is controlled and therefore require rhythm control drugs. They may be safe and effective however if used in selected patients. In cases of Afib with RVR these medications may need to be used if patients cannot tolerate other rate control medications.

Ablation Procedures

Ablation procedures are minimally invasive procedures typically done through the groin. They are typically used in patients that have tried, or cannot tolerate medicines for control of AFib. Ablation is typically not used as an emergency treatment of Afib with RVR, rather it is used for stable patients in AF, or those with intermittent AFib that wish to remain in normal rhythm. In patients that have had persistent Afib for a long time these procedures are not likely to be successful in the long term.

Pacemaker

This is typically the last throw of the dice for AF control. In some patients, drugs can either not control the rate in AFib with RVR, or the drugs can simply not be tolerated. In these patients who have no other choice, and in whom it is determined the Afib is causing harmful effects, a procedure called AV node ablation and pacemaker is done. In a relatively minor procedure, a small burn is made to the connection that connects the top and bottom chambers of the heart. A pacemaker is then inserted. This prevents Afib with RVR as although the top chambers continue to fire at a fast rate, the pacemaker now controls the bottom chamber, in a nice regular way. The downside of course is that now although the patient cannot have Afib with RVR, they have a pacemaker.

Acute afib RVR patients are more likely to be converted to Normal Sinus Rhythm (the best rhythm you could be in) as opposed to patients with chronic afib. There are complete resolutions for both kind of afib but atrial fibrillation in RVR the heart can handle for only so long and remembering the engine of our body is the heart so take good care of it for if you don’t it could allow you to die.

“The heart weighs between 7 and 15 ounces (200 to 425 grams) and is a little larger than the size of your fist. By the end of a long life, a person’s heart may have beat (expanded and contracted) more than 3.5 billion times. In fact, each day, the average heart beats 100,000 times, pumping about 2,000 gallons (7,571 liters) of blood.”

Texas Heart Institute

Lets review the anatomy of the heart, our bodies oxygen is the food to our tissues in keeping them alive through our red blood cells (RBC’s) that carry the O2 to the tissues through a heart and lungs working properly.  The heart in pumping and the lungs in inspiration/expiration (one organ cannot live without the other).

There has to be a systemic way we allow this to work and this is through the heart, lungs, and RBC’s (3 systems that connect with each other). The heart = right side deals with more C02 blood than 02 blood which is blood returning to the heart to get more 02 going first via the Rt. side of the heart to the pulmonary artery, each of which carries blood to the lungs for 02 and C02 exchange to occur. This is for getting more 02 in our RBC’s with allowing them to release C02 at the lungs bases and then return to the left side of the heart.  On the left side of the heart this is blood to be sent through both Lt. chambers (Lt. atria first  and then the Lt. ventricle) of the heart to our blood stream to utilize the new 02 in our RBC’s that they intially obtained at our lungs going now to our body tissues. This is a 24hr/7days a week job for our red blood cells, lungs and heart in functioning to keep the human body alive.

In simpler terms this is how it works: The blood that needs to be refreshed with more 02 always which takes place by the blood in our body entering the right (Rt.) atrium coming from a vessel that brings back mainly carbon dioxide in the blood from the toes and the brain that was previously oxygenated blood that mainly was used up by the tissues and those RBC’s returning on the right side of the heart need to be reoxygenated with higher levels of oxygen.  For the RBC’s to deliver 02 again to tissues in redoing this process all over again it goes through a pathway=our circulatory system.  When the red blood cells need more oxygen it first goes to the Rt. atrium & fills up to its max level in that chamber to going to the Rt Ventricle than through the pulmonary artery to the lungs to get more 02.  Simultaneously while the Right side of the heart does this the left (Lt.) atrium is filling up to its max level than goes to the Lt. Ventricle and out the Aorta to the arteries throughout the body to carry 02 to our tissues through the RBC’s carrying the 02.   Ending line when the Rt. atrium is ready to drop its blood max level into the Rt. ventricle the Lt side does the same thing.  The difference is the 02 and C02 content in Rt and Lt side of the heart (Right side is more C02 in the RBC’S whereas the Left side has more 02 content in the RBCs/blood.

For the blood to get to the atriums to the ventricles they have valves; they open between the chambers simultaneously (the tricuspid valve on the right side and mitral valve on the left side) dropping the blood to the lower chambers of the heart happens simultaneously but only the Rt. side ends up going to the lungs through a pulmonary artery to get more oxygen to send the highly oxygenated blood to the L (left) side of the heart. The job the Rt. side of the heart does this, it just goes from the Rt. side of the heart to our lungs and back to the heart on the Lt. side through the pulmonary veins to the L atrium than the Lt Ventricle going to the aorta this blood gets sent throughout the body; so the path or distance for the Rt. side of the heart to do its function is a short distance = it gets your used up oxygen in the red blood cells (that are high in carbon dioxide) to get more oxygen by going through the Rt. side of the heart sending them to the lungs where they get more O2 and then they are sent back to the Lt. side of the heart.   This is the Rt. side of the heart’s function and explains why the heart muscle on that side of the heart is smaller than the Lt. side.  Now let us look at what the Lt. side of the heart, in what blood it delivers to our tissues with our red blood cells (RBC’s).   The RBC’s reoxygenated that leave the lungs and are sent via the pulmonary vein to the Lt. side of the heart, reaching the Lt. atrium, thus carries a high 02 level in the RBC’s (this blood just came directly from the lungs where O2 and CO2 exchange for the RBC’s took place).  Next the RBC’s go to the Lt. ventricle to our Aorta that sends this high oxygen level of RBC’s out to all our tissues as food to prevent starvation of the tissues.   Again, when the valves open between the chambers of the heart and allowing this blood to fill up in the lower chambers called the Rt. and Lt. ventricles it is simultaneously done.   Also including the valves that open and close in the heart the pulmonary artery and the aorta or the tricuspid valve and mitral valve are simultaneous as well.  The ventricle sending RBC’s out to our circulatory system high in O2 to be utilized by our body tissues is the Lt. Ventrilcle. To do this job takes more effort as opposed to the Rt. side of the heart and that is why the Lt side of the heart has a bigger muscle mass (more of a work out for that side of the heart).

So the way it works with both sides of the heart is the Rt. side sends blood of highly carbon dioxide blood (RBC’s) to the lungs to get re-oxygenated through 2 vessels from the Rt. side of the heart to the lungs that sends this re-oxygenated blood in the RBC’s through 2 vessels.  On the Rt side of the heart you have the Superior Vena Cava which enters the C02 blood into the right atrium and the 2 pulmonary arteries that send that blood from the Rt Ventricle to the lungs to get the 0xygen from them.  Than this blood goes to the Lt. side of the heart  sends this highly oxygenated blood now throughout the top and bottom of the Lt. side of the heart through 2 vessels which are the pulmonary veins dumping the blood in the Lt atrium down into the Lt ventricle and out the aorta that sends this blood throughout our body tissues.  When this oxygen is used all up from the RBC’s dispensing it out to tissues the C02 is taken back from the tissues by RBC’s that replace it with O2 through breathing;   this process starts all over again with these RBC’s returning to the right side of the heart reaching the lungs to get more oxygen to be sent out by the left side of the heart to go out to all our tissues. Ending line the right side of the heart is for higher levels of carbon dioxide in the blood (used up oxygenated blood) to get more oxygen through our RBC’s whereas the left side of the heart sends higher levels of O2 throughout the body all the way to the toes through the RBC’s (a harder job on the left side of the heart=muscle mass of the left side of the heart works out more than the right making the left side of the heart a bigger muscle vs the right side).

Now knowing the anatomy and physiology of the heart let’s now understand more about a cardiac disease RVR=Rapid Ventricular Rate and Atrial Fibrillation and more regarding how they develop and in how it effects the engine of the body, being the heart, and the lungs=the transmission of the body. Like a car if the engine is affected in time the transmission gets affected and if not repaired by the mechanic the car engine will die with the transmission. Same effect with the human engine=the heart. If the heart is affected in time it will effect the lungs and if not repaired the heart will die and so will the lungs with the rest of the body.

Tomorrow Part 2 on Rapid Ventricular Rate and A Fib in how it affects the heart in functioning but how it can be treated to live a fairly normal life.

“In short most of us think of sleep as a passive and relatively constant and unchanging process. In fact, sleep is a very active state. Our bodies move frequently, as we roll about during the night, and, more importantly to the psychologist, our brain activity is even more varied than it is during the normal waking state.”

Dement, W.C. (1978). Some must watch while some must sleep. New York: W.W. Norton.

Pinel, J.P.J. (1992). Biopsychology. Needham Heights, MA: Allyn & Bacon.

“If you have norovirus, don’t prepare food for at least two to three days after you feel better. Try not to eat food that has been prepared by someone else who is sick.”

WEB MD.

Norovirus is a very contagious virus that can infect anyone. You can get it from an infected person, contaminated food or water, or by touching contaminated surfaces. The virus causes your stomach or intestines or both to get inflamed. This leads you to have stomach pain, nausea, and diarrhea and to throw up. These symptoms can be serious for some people, especially young children and older adults.

Anyone can be infected with norovirus and get sick. Also, you can have norovirus illness many times in your life. Norovirus illness can be serious, especially for young children and older adults.

Norovirus is the most common cause of acute gastroenteritis in the United States. Each year, it causes 19-21 million illnesses and contributes to 56,000-71,000 hospitalizations and 570-800 deaths. Norovirus is also the most common cause of foodborne-disease outbreaks in the United States.

The best way to help prevent norovirus is to practice proper hand washing and general cleanliness.

Norovirus can be found in your stool (feces) even before you start feeling sick. The virus can stay in your stool for 2 weeks or more after you feel better.

You are most contagious

• when you are sick with norovirus illness, and
• during the first few days after you recover from norovirus illness.Norovirus and foodNorovirus outbreaks can also occur from foods, such as oysters, fruits, and vegetables, that are contaminated at their source.
• Norovirus is the leading cause of illness and outbreaks from contaminated food in the United States. Most of these outbreaks occur in the food service settings like restaurants. Infected food workers are frequently the source of the outbreaks, often by touching ready-to-eat foods, such as raw fruits and vegetables, with their bare hands before serving them. However, any food served raw or handled after being cooked can get contaminated with norovirus.
• You can become infected with norovirus by accidentally getting stool or vomit from infected people in your mouth. This usually happens by

• eating food or drinking liquids that are contaminated with norovirus,
• touching surfaces or objects contaminated with norovirus then putting your fingers in your mouth, or
• having contact with someone who is infected with norovirus (for example, caring for or sharing food or eating utensils with someone with norovirus illness).SIGNS/SYMPTOMS OF NOROVIRUS: Diarrhea/Vomiting/Nauses/Dehydration/Stomach Pain/Fever/Headache/Bodyaches.A person usually develops symptoms 12 to 48 hours after being exposed to norovirus. Most people with norovirus illness get better within 1 to 3 days.You can become infected with norovirus by accidentally getting stool or vomit from infected people in your mouth. This usually happens by
• You are most contagious when you have symptoms with the norovirus, during the first few days after you have recovered from norovirus.
• If you have norovirus illness, you can feel extremely ill and throw up or have diarrhea many times a day. This can lead to dehydration, especially in young children, older adults, and people with other illnesses.
• Norovirus can spread quickly in closed places like daycare centers, nursing homes, schools, and cruise ships. Most norovirus outbreaks happen from November to April in the United States.

• eating food or drinking liquids that are contaminated with norovirus,
• touching surfaces or objects contaminated with norovirus then putting your fingers in your mouth, or
• having contact with someone who is infected with norovirus (for example, caring for or sharing food or eating utensils with someone with norovirus illness or kissing someone with the virus).Norovirus can spread quickly in closed places like daycare centers, nursing homes, schools, and cruise ships. Most norovirus outbreaks happen from November to April in the United States.  I personally was on a cruise that ended up having this and was from the previous trip the ship took but didn’t find out about it till I saw a note with my husband on our pillows in our ship room at that point we were given the opportunity to cancel and reschedule our trip.  Cruise line tactic to now have you cancel the trip and not return your bags till the end of the ship cruise along with all that going through security like us we stayed on and took the chance.  I ended up not with it or my husband and the cruise went to simple infection control techniques to strict when it affected the people which offended many but not us.  Being an RN several years I understood they were doing better infection control tactics but should have started from day one and explained to all.  That could be hard on a cruise of people not just from USA.
• Protect Yourself and Others from Norovirus
• What areas are with higher probability in having the disease?  PUBLIC PLACES in particularly the following:

• Practice proper hand hygiene Wash your hands carefully with soap and water, especially after using the toilet and changing diapers and always before eating or preparing food. If soap and water aren’t available, use an alcohol-based hand sanitizer. These alcohol-based products can help reduce the number of germs on your hands, but they are not a substitute for washing with soap and water.
• Take care in the kitchen Carefully rinse fruits and vegetables, and cook oysters and other shellfish thoroughly before eating.
• Do not prepare food while infected People with norovirus illness should not prepare food for others while they have symptoms and for at least 2 days after they recover from their illness. Also see For Food Workers: Norovirus and Working with Food.
• Clean and disinfect contaminated surfaces After throwing up or having diarrhea, immediately clean and disinfect contaminated surfaces using a bleach-based household cleaner as directed on the product label. If no such cleaning product is available, you can use a solution made with 5 tablespoons to 1.5 cups of household bleach per 1 gallon of water.
• Wash laundry thoroughly Immediately remove and wash clothing or linens that may be contaminated with vomit or stool. Handle soiled items carefully—try not to shake them —to avoid spreading virus. If available, wear rubber or disposable gloves while handling soiled clothing or linens and wash your hands after handling. Wash soiled items with detergent at the maximum available cycle length and then machine dry.Good hygiene is the key to preventing an infection with norovirus, especially when you are in close surroundings with a lot of other people.QUOTE FOR ARTICLE:
• Regarding the treatment,  unfortunately there is no specific medicine to treat people with norovirus illness. Norovirus infection cannot be treated with antibiotics because it is a viral (not a bacterial) infection. If you have norovirus illness, you should drink plenty of liquids to replace fluid lost from throwing up and diarrhea.  Give children an oral rehydration solution (like pedialyte) to replace lost fluids and  electrolytes.  Avoid sugary drinks, which can make diarrhea worse, as well as alcohol and caffeinated beverages, which can dehydrate you further.

“Hepatitis types B and C lead to chronic disease in hundreds of millions of people and, together, are the most common cause of liver cirrhosis and cancer.”

WHO World Health Organization

“According to some studies, however, up to almost half the people who had polio at a young age may experience certain effects of the disease many years later — post-polio syndrome.”

MAYO CLINIC

“The words polio (grey) and myelon (marrow, indicating the spinal cord) are derived from the Greek. It is the effect of poliomyelitis virus on the spinal cord that leads to the classic manifestation of paralysis.”

Centers for Disease Control and Prevention