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Atriumfibrillatie

ATRIUMFIBRILLATIE

  

Mechanismen

- Chaotische atriale activiteit (350 - 600/min)
- geen goede atriale contracties
- reactie van de ventrikel : AV nodulus remt de doorgang van de impulsen af tot 160-200/min
- gevolgen
- verminderd slagvolume en cardiac output
- spontane reconversie: bij eerste keer vaak spontane reconversie binnen 24u.
-  Bij 30% herneemt het sinusritme zonder medicatie.
- complicaties:
- mortaliteit verdubbelt
- CVA: bij 35% van casi.  Embolen worden vaak afgeschoten bij reconversie.
           Hersenbloedingen worden gezien bij anticoagulatie
- syncope
- angor
- darmischaemie

- bij therapie: digitalisintoxicatie

 

Risicofactoren om atriumfibrillatie te ontwikkelen

- idiopathisch
- cardiaal
- coronair vaatlijden
- hypertensie
- mitraliskleplijden
- chronische pericarditis
- Wolff-Parkinson-White syndroom (WPW)
- Longen
- longembolen
-chronisch longlijden
- Hypothyroidie
- Ethylisme

 

2. Kliniek

- Altijd
- onregelmatige pols
- auscultatie: onregelmatige hartslag, S1 variabele intensiteit
- Monitoring: onregelmatig; af en toe geen QRS-complex
- Stabiele patiënt
- palpitaties
- dyspnee
- zwakte
- ijl hoofd
- syncope
- Instabiele patiënt
- hypotensie
- persistente angor
- longoedeem

- BWZ-daling

 

3. Diagnostiek

- ECG: geen duidelijke P-toppen
- Labo: CBC, Elektrolyten, hartenzymen, schilklierfunctie
- Pulse oxymetrie
- echocardio: is er atriale uitzetting? (als oorzaak)
                    is er een atriale thrombus (onmiddellijke anticoagulatie)

 

4. DD

- atriale flutter met wisselende AV-blok
- Multifocale atriale tachycardie
- sinusritme met frequente premature atriale contracties
- atriale tachycardie

 

 

Eerste opvang

- is de patient stabiel?
- indien ja: gewoon transport naar het ziekenhuis
- indien nee: onmiddellijke reconversie en ALS
- zuurstof
- IV-lijn
- monitoring

 

Spoeddienst
 
  Smal complex Tachycardie
- Wanneer moet therapie gestart worden? vraag: is de patient stabiel?
- Indien neen: reconversie
- indien ja:
- HR > 100/min:  geen therapie
- HR 100 - 120/min: indien stabiel geen therapie.  Indien niet stabiel wel therapie
- HR > 120/min: therapie
- Welke therapie?
- Cardioversie:
- indicaties:
- ofwel onstabiele patient
- ofwel stabiele patient zonder mitraliskleplijden, zonder linkerventrikeldysfunctie en zonder CVA in de voorgeschiedenis én met atriumfibrillatie < 48 uur aanwezig (geen heparinisatie nodig) of > 48 uur aanwezig maar geen thrombus zichtbaar op echocardio. In dit geval wel eerst hepariniseren ( 80 I/kg LG in bolus en nadien continu infuus aan 18IU/kg/u)
- manier van handelen
- sedatie
- cardioversie synchroon.  Begin met 100J
- Beta-blokkers
- Sotalol (Sotalex):
- cave nierinsufficientie.
- Risico torsade de pointes.  Goed monitoren bij opstarten medicatie!
- Posologie: 2dd van 80-160 mg PO (1co = 160mg)
- Metoprolol (Lopressor, Selozok)
- posologie: 100 - 300 mg/d in 1-2 giften PO
- Propanolol (Inderal, Propanolol)
- posologie: 80 - 240 mg/d in 2-4 giften PO
- Digoxine (vooral bij chronisch hartfalen)
- posologie: Bolus 0,5 mg IV, dan 0,25 mg IV elke 4u tot gewenste effect
- nadien overstappen op PO
- Procainamide
- Indien mogelijke WPW of indien geen reactie op andere medicatie
- posologie: infuus aan 0,2 - 0,5 mg/kg/min
- Calciumantagonisten
- Diltiazem (Tildiem) : voorkeursproduct
- 0,25mg/kg IV bolus over 2 minuten
- zo nodig na 15 minuten 0,35 mg/kg IV over 2 minuten
- Verapamil (2e keuze)
- risico hypotensie
- posologie: 2,5 - 5 mg IV bolus over 2 min
- zo nodig na 15-30 min 5-10mg IV tot maximum 20 mg IV
- contra-indicaties: WPW-syndroom, patient neemt reed betablokkers, breed complex tachycardie.
 
  Breed complex Tachycardie
- Is de patient stabiel?
- indien neen:
- cardioversie
- ALS
- indien ja:
- Procainamide
- vermijd calciumantagonisten, betablokkers en digoxine
- indien risco op WPW-syndroom:
- geen calcium-antagonisten (Verapamil)
- Bretylium
- Adenosine: best alleen voor supraventriculaire.  Eerst 6 mg snel IV.  Zo nodig herhalen na 2 minuten (12 mg)

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