Talk:Atrial fibrillation

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This article was previously a Medicine Collaboration of the Week.

Contents 1 What this article needs 2 "Maze" v. "maze" procedure 3 Lone afib 4 Symptoms 5 Electrocardiogram 6 More about classification and treatment 7 External Links 8 Normal vs AFib conduction image 9 Afib vs sinus

[edit] What this article needs

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)

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

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)

[edit] Lone afib

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

[edit] Symptoms

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)

[edit] Electrocardiogram

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)

[edit] More about classification and treatment

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)

[edit] External Links

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

[edit] Normal vs AFib conduction image

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)

[edit] Afib vs sinus

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)