CILIARY ARRHYTHMIA (Greek arrhythmia lack of a rhythm, unevenness; synonym: atrial fibrillation, fibrillation of auricles, arrhythmia perpetua, pulsus perpetuus irregularis, delirium cordis, fibrillatio et tachysystolia atriorum) — the disturbance of a heart rhythm which is characterized by frequent and irregular vozbuzhdeniye of a myocardium of auricles and full heterogeneity of cordial reductions on the frequency and force and duration of cardial cycles considerably fluctuates and has accidental character. In one group with M. and. clinical physicians combine usually and other type of atrial disturbances of a rhythm — an atrial flutter, at Krom the heart rhythm periodically or constantly remains correct. Such association is proved by the fact that an etiology, patol, the physiology and a wedge, a picture of arrhythmia during the blinking and an atrial flutter are similar, and transformation of blinking in trembling and vice versa, and also the mixed forms is possible. One of differences of blinking from an atrial flutter revealed on an ECG — various frequency of excitation waves of auricles: at M. and. it makes more than 300 in 1 min. (usually 500 — 800 in 1 min.), during the trembling — less than 300 in 1 min.
The state which is characterized by full disorder of pulse and cordial reductions is known long ago. Zh. Buyo (1835) and G. I. Sokolsky (1836) noted that it is characteristic of many patients with rheumatic heart diseases. Zh. Buyo designated it as «nonsense of heart» (delirium cordis). In 1874
A. Vyulpian, in an experiment observed emergence of chaotic twitching of fibers of a myocardium of auricles at impact on them the condenser category. The glossy surface of auricles at the same time flickers, reminding ripples on a water surface in this connection this fortune was come into by the name «atrial fibrillation». Other its name — «fibrillation of auricles» is connected with existence of reductions of myocardial fibers in the absence of reduction of all myocardium as whole. J. A. Me William in 1877 observed in an experiment emergence of very frequent, but arranged reductions of a myocardium of auricles under the influence of the category of the condenser; this state was called an atrial flutter. On an ECG atrial fibrillation at the patient for the first time was registered by V. Eyntkhoven (1904). G.F. Lang (1916) suggested to call arrhythmia at atrial fibrillation ciliary.
Depending on the frequency of reductions of ventricles of heart allocate takhisistolichesky (more than 100 reductions in 1 min.) and bradisistolichesky (less than 70 reductions in 1 min.) forms M. and. Such division is considerably conditional. It is considered to be that for a takhisistolichesky form M. and. not only high frequency of cordial reductions, but c the existence of deficit of pulse which is shown the fact that the frequency of reductions of ventricles of heart exceeds pulse rate is characteristic. However deficit of pulse at the same patient can be absent at rest and appear at loading. Sometimes, besides, speak about eusistolichesky (or what is wrong, about normosistolichesky) a form M. and., at a cut the frequency of reductions of ventricles within norm and deficit of pulse is absent. Depending on whether disturbance of a cordial rhythm in the form of attacks proceeds or has constant character, it is accepted to allocate also constant and paroxysmal forms M. and. If disturbance of a rhythm continues more than 10 days, it can be considered constant.
The atrial flutter can be followed by the correct and wrong rhythm of reductions of ventricles of heart. In the first case of reduction of ventricles are regular since they arise in response to everyone one, two, three etc. reductions of auricles. The wrong rhythm of reduction of ventricles is observed at an atrial flutter with the changing ratio between number of reductions of auricles and ventricles: ventricles are reduced after one, after two, after three etc. reductions of auricles. The described two forms are associated since at them reductions of ventricles are connected on time with a certain reduction of auricles; occasionally such communication is absent, and reductions of ventricles become absolutely irregular (the dissociated atrial flutter).
M. and. treats common forms of disturbances of a cordial rhythm. Most often it is observed at patients with coronary heart disease, at an atherosclerotic and miokarditichesky cardiosclerosis, mitral heart diseases (especially mitral stenosis) and a thyrotoxicosis. In more exceptional cases as the reasons of its emergence serve disturbances of a hemodynamics and change of a myocardium at myocardites, cardiomyopathies. Seldom or never M. and. is a consequence of injuries of heart, including the operating room, irritation of auricles the probe or their electric stimulation, an electric trauma. Cases of emergence of M. are known and. at toxicoinfections (pneumonia, typhus, etc.), and also intoxications (carbon monoxide, sympathomimetic amines, cardiac glycosides, etc.). According to different authors, the acute myocardial infarction is complicated by M. and. in 5 — 17% of cases. Even less often this disturbance of a rhythm is observed at an embolism of a pulmonary artery, and also at patients with a pulmonary heart. Family M.'s cases are described and. in combination with an otosclerosis or without it. M. is frequent and. it is combined with Wolff's syndrome — Parkinson-Whyte (see. Wolff-Parkinson-Whyte syndrome ). M.'s paroxysms and. sometimes arise at a considerable psychoemotional tension or soon after it. In this regard many scientists assume that M. and. can have purely psychogenic origin. However it is more probable that in similar cases psychoemotional factors play only a role of a releaser of arrhythmia at people with organic changes of auricles or with existence of premises to their ischemia (a peculiar form of coronary heart disease).
For an explanation of a pathogeny of M. and. several theories were offered, from to-rykh two are considered as the main: theory of the multiple centers of automatism and theory of a circular excitation wave. The essence of the first theory created by D. Scherf comes down to the fact that under certain conditions, napr, at a long overstrain of auricles or emergence in their walls of the centers of dystrophy or a cardiosclerosis, in a myocardium of auricles the set discordantly of the functioning centers of automatism is formed. Coming from impulses of these centers partially interfere, partially directly excite an adjacent myocardium therefore reduction of fibers of a myocardium of auricles becomes absolutely chaotic. According to the second theory offered by Lewis (Th. Lewis, 1914), under the conditions described above are created premises for roundabout of an excitation wave on a myocardium of auricles around openings of venas cava. From this main wave secondary waves tsentrobezhno separate, to-rye, interfering with each other, cause chaotic reductions of muscle fibers of a myocardium of auricles. The idea of circulation of an excitation wave gained development in the theory of a repeated entrance of excitement to a myocardium (re-entry) which gained the greatest recognition. This theory consists that in a myocardium there are premises for circulation of excitement and a repeated entrance of its wave to those sites, from to-rykh it came to patholologically the changed area (fig. 1). Quite often such situation results from the atrial extrasystole exciting a myocardium while not all its fibers came out a condition of a refrakternost (the so-called phase of vulnerability of auricles on an ECG corresponding to approximately descending piece of a tooth of R or initial department of a segment S — T). In favor of the theory of a repeated entrance of excitement to a myocardium the possibility of reproduction of atrial fibrillation by means of the single electric incentive put in the period of vulnerability of auricles (the first criterion of the re-entry mechanism on Vellensa), and also an opportunity to eliminate atrial fibrillation by means of impact on a myocardium of electric discharge of high tension testifies. The phase of vulnerability of auricles is always available for dogs. It is unknown whether it is characteristic of an intact myocardium of the person or always serves as display of pathology. In any case at diagnostic stimulation of auricles of heart at the person M. and. arises seldom. In addition to the first criterion of Vellens, we will apply to an atrial flutter also the second — an opportunity to eliminate arrhythmia by means of a single electric incentive of small tension.
Blinking and an atrial flutter is in most cases started by an atrial extrasystole. In an origin of premature ventricular contraction «starting» blinking or an atrial flutter, the big role belongs to disturbances of ionic balance, especially gipokaligistiya of a myocardium. However deficit of potassium, apparently, is not an indispensable condition neither for emergence, nor for maintenance of blinking and an atrial flutter.
An irregularity of reduction of ventricles at M. and. is explained by a so-called dekrementnost of carrying out excitement in atrioventricular connection, or the hidden carrying out excitement. The atrioventricular node is capable to extinguish weak impulses of excitement, passing stronger (decrement of carrying out); at the same time the refrakternost of an atrioventricular node especially is long, than the impulse is stronger. All this promotes carrying out to ventricles enough strong impulses; the probability of passing of weak vozbuzhdeniye through an atrioventricular node is reduced.
The clinical picture
the Clinical picture is extremely variable. Complaints of patients and objective manifestations of M. and. are defined by specific features of the patient and extent of preservation funkts, opportunities of ventricles of heart, hl. obr. left. The worse funkts, the condition of ventricles, the is more possibility of development acute or hron, heart failure (see). A part of patients does not notice M.'s emergence and., others feel uncertain unpleasant feelings in heart, but most often patients feel sudden emergence of chaotic heartbeat, more rare than the speeded-up, strong, but rhythmical heartbeat (at an atrial flutter with regular reductions of ventricles). If the frequency of reductions of ventricles is very big, sharp weakness, dizziness, subconscious state and even a short-term syncope are observed. In nek-ry cases, when M.'s emergence and. it is connected with a paroxysm of vegetative dysfunction of hypothalamic genesis (see. Hypothalamic syndrome ), there can be at the same time symptoms of other vegetative frustration, is more often than adrenergic type (sensation of fear, a shiver, a polyuria). Over time all unpleasant feelings, as a rule, disappear (independently or under the influence of treatment) though heartbeat can long disturb the patient at certain provisions of a body (e.g., lying on the left side) or at a physical and psychoemotional tension.
The only pathognomonic sign of atrial fibrillation — full disorder of pulse and cordial reductions. Pulse blows follow one after another through unequal time terms (sometimes time between reductions of heart at one patient fluctuates from 0,3 — 0,5 to one and a half-two seconds). Force, speed and tension of pulse change from blow to blow. Also the loudness of cardiac sounds is also changeable: the diastole, the first tone more loudly following it is shorter. At repeated measurements of the ABP inconstancy of systolic pressure is noted. Often, especially at a takhisistolichesky form M. and., note the deficit of pulse caused by the fact that during the systoles coming after short diastoles, the amount of the blood which is thrown out in an aorta is not enough for formation of pulse wave on peripheral arteries.
At an atrial flutter it is possible to note nek-ry orderliness of pulse and cordial reductions as pulse blows and reductions of heart follow one after another through equal or multiple to some certain size time terms. At the correct rhythm of reductions of ventricles of heart their frequency depends on coefficient of carrying out impulses of excitement from auricles to ventricles. Most often this frequency makes apprx. 150 reductions in 1 min. (carrying out 2:1), it is more rare apprx. 100 (carrying out 3:1) and it is very rare apprx. 300 (carrying out 1:1). Lack of a respiratory arrhythmia is characteristic. However the exact diagnosis can be made only on the basis of the analysis of an ECG.
In rare instances (at intoxication cardiac glycosides, at patients with a myocardial infarction and it is extremely rare at other patol. states) blinking or an atrial flutter is combined with a total atrioventricular block. At the same time the correct, but rare rhythm is observed (usually less than 50 reductions of ventricles of heart 1 minute), the specified state carries the name of a phenomenon of Frederik (see. Heart block ), revealed only elektrokardiografichesk.
On an ECG at atrial fibrillation (fig. 2 and 3) due to the lack of their rhythmic activity there is no atrial tooth of River. All pieces of an ECG between the QRS complexes are filled with small irregular waves of fibrillation (a wave of f). Average frequency of these waves — 600 — 800 in 1 min.
Waves of f can be larger and absolutely small in this connection nek-ry distinguish large and melkovolnovy fibrillation of auricles, however this distinction has no basic character. Waves (or teeth) are especially well visible to fibrillation on the elektrogramma which is written down from a cavity of auricles (fig. 4) and also on the esophageal ECG. It is important during the carrying out the differential diagnosis of M. of ampere-second nek-ry other disturbances of a heart rhythm, e.g., supraventricular tachycardia as in nek-ry cases at a ciliary tachyarrhythmia the QRS complexes can follow one by one with almost correct intervals. Registration of an atrial elektrogramma helps to distinguish also M.'s paroxysm of ampere-second the broken intra ventricular conductivity from ventricular tachycardia.
At an atrial flutter the tooth of P on an ECG is also absent, and between the QRS complexes waves of trembling — a wave with a frequency of 250 — 300 of 1 min. of (fig. 5 and 6), to-rye on the esophageal ECG are visible, and also to an intra atrial elektrogramma come to light as sharp-pointed teeth (fig. 7). On usual ECGs more accurately waves of an atrial flutter are registered in assignments of II, III, AVF and V1. Smooth transition of one wave of F to another (in assignments of II, III, aVF) without flat isoelectric interval between them as it is always observed between atrial waves of supraventricular tachycardia is characteristic of an atrial flutter. The QRS complexes at the associated atrial flutter follow every second, every third wave of F; at dissociated — behind one, behind two, behind three, four etc. waves. Communication of the QRS complex with quite certain phase F is characteristic of the associated atrial flutter even if trembling has irregular character; at the dissociated trembling this communication is lost. Also cases when on an ECG this or that number of waves of trembling alternates with waves of blinking — so-called blinking - an atrial flutter are observed.
Fibrillation of auricles can be complicated by formation of blood clots in them. Formation of the big spherical blood clots in the left auricle from time to time closing an atrioventricular opening that is followed by all manifestations of a sudden stop of cordial activity is sometimes observed at the mitral stenosis complicated by M. and. Much more often trombotichesky masses comes off that leads to a vascular embolism of a big or small circle of blood circulation. This complication is more often observed at M. and. at patients with heart diseases, especially at a mitral stenosis, at Krom in connection with dilatation of the left auricle and often observed damages of its endocardium the conditions promoting a thrombogenesis especially easily are created. Occasionally thromboembolisms arise at patients with M. and. without defeats of the valve device of heart, in particular at atherosclerosis, for to-rogo tendency to hypercoagulation is characteristic. For an atrial flutter tromboembolic episodes are generally atypical since sokratitelny activity of auricles, though in the changed form, remains.
Eusistolichesky form M. and. in itself, as a rule, does not lead to heart failure, but at the expressed changes of a myocardium of ventricles of heart or the valve device can be the factor promoting its emergence. Disturbance of blood circulation is possible at a takhisistolichesky form M. and., especially with big deficit of pulse. More rare them the bradisistolichesky form M. happens the reason and. (usually in combination with disturbances of conductivity on atrioventricular connection). If disturbance of blood circulation is caused only M. and., usually it completely disappears at recovery of a sinoatrial rate or at normalization of frequency of ventricular reductions. Heart failure most often proceeds on left ventricular type with insufficient cordial emission though also edematization of lungs in a few minutes or after M.'s emergence is possible hours and. If the myocardium of the right departments of heart is affected, then also right ventricular insufficiency develops. Hron, heart failure at M. and. can proceed with aggravations in the form of cardiac asthma.
At treatment of the patient with M. and. a number of circumstances is considered: what disease is the cornerstone of disturbance of a rhythm whether the patient feels arrhythmia in what measure the hemodynamics suffers from it, disturbance of a rhythm is constant or paroxysmal what frequency and duration of paroxysms,
In rather small number of cases perhaps etiol, treatment. So, adequate use of tireostatik or a strumectomy for patients with the diffusion toxic craw complicated by M. and., quite often leads to normalization of a heart rhythm or provides high performance of antiarrhythmic therapy. The operational korrigirovaniye of heart diseases at a number of patients creates conditions for successful fight against M. and. At impossibility etiol, treatments it is necessary to resolve an issue whether the patient in general needs therapy and if needs, then in what. If the patient has a bradisistolichesky form M. and., and he does not feel any related unpleasant feelings, it has no hemodynamic disturbances and premises to a thrombogenesis, special treatment is not carried out. Observations of many authors show that attempts to normalize a heart rhythm in these cases are inefficient; as a rule, the recovered rhythm remains not for long.
At paroxysmal M. and. therapeutic tactics pursues two aims: the prevention of attacks or their urezheniye and simplification of a current and stopping of attacks at their emergence. If attacks rare, are followed by the minimum unpleasant feelings and do not lead to disturbances of a hemodynamics, is inexpedient to warn them since all pharmaceuticals applied to this purpose sometimes give side effects. In similar cases individually select medicine for stopping of an attack.
In the conditions of ambulance for stopping of a paroxysm of M. and. most often apply novokainamid. Intravenously enter 2 — 3 ml of 10% of solution of drug; in the absence of effect repeat its introduction in the same dose every 4 — 5 min. while total quantity of the entered solution does not reach 10 ml (1 g of a novokainamid). Introduction of high doses demands experience since development of a collapse, disturbances of conductivity and even fibrillation of ventricles is possible. In all cases at introduction of a novokainamid it is necessary to control often the ABP and in case of development of a collapse to enter a phenylephine hydrochloride or other adrenomimetik (see. Collapse ). If the sinoatrial rate was not recovered, slowly enter 0,5 — 1 ml of 0,05% of solution of strophanthin or 1 — 1,5 ml of 0,06% of solution of Korglykonum diluted with 10 ml of isotonic solution of sodium chloride into a vein. It is possible to use also blockers of beta and adrenergic receptors, napr, Obsidanum (propranolol). Contents of an ampoule — 5 mg of propranolol — dissolve in 10 ml of isotonic solution of sodium chloride and by means of the syringe slowly (within 5 min.) enter into a vein under control of an ECG and the ABP. Even if under the influence of these actions the sinoatrial rate is not recovered, heart rate nevertheless considerably decreases. Existence during M.'s paroxysm and. displays of heart failure demands obligatory intravenous administration of cardiac glycosides, and if necessary and other means (see. Cardiac asthma ). M. applied sometimes to treatment and. verapamil (Isoptinum) almost never leads to normalization of a rhythm, but urezhat cordial reductions. There are data on favorable action of Amiodaronum (kordaron) entered intravenously in a dose of 200 mg. Under its influence the normal rhythm can be recovered or the ciliary tachyarrhythmia passes into a bradisistolichesky form. It is necessary to emphasize danger of use of cardiac glycosides, and on a nek-eye to the data, and verapamil at M. and. the patient with Wolff's syndrome — Parkinson — Whyte; in these cases under the influence of the specified means emergence of an imbalance in carrying out an impulse of excitement on the basic and the additional carrying-out way and transition of atrial fibrillation to ventricles is possible.
If the attack of arrhythmia does not give in to effect of medicines, it is stopped transthoracic electric discharge of high tension (see. Defibrillation ).
In stationary conditions to the patient with paroxysmal M. and. select the means allowing to stop attacks at oral administration. It gives the chance to reduce the frequency of calls the patient of ambulance crews after an extract and, besides, has psychotherapeutic effect as helps the patient to treat M.'s attacks and. without panic fear that is observed quite often. It is impossible to select such treatment in house conditions because of a possibility of side effect of antiarrhythmic means. If in stationary conditions it becomes clear that the patient well transfers certain drugs, it is possible to recommend it independent reception of these drugs in the picked-up dose of the house. Quinidine is most effective. It is appointed out of an attack in a trial dose 0,05 — 0,1 g for a single dose to find out whether is not present at the patient of an idiosyncrasy to this drug. During an attack it is recommended to accept 0,4 g of quinidine that in most cases leads to creation within an hour from the moment of reception of efficiency concentration of medicinal substance in blood. If the rhythm is not recovered, every 2 hour give still 0,2 g of quinidine before normalization of a rhythm or before achievement of the general dose of 1 g (and at quite good tolerance — to 2 g). The patient who is not transferring quinidine appoint novokainamid in a dose of 1 — 1,5 g and further every 2 hour on 0,5 g, the effect will not occur yet or the general dose of 2,5 — 3 g will not be reached. Other antiarrhythmic means at oral administration of patients with M. and. do not possess a little reliable stopping action. Apply also various combinations of drugs to stopping of paroxysms.
The combination of 0,4 g of quinidine from 20 — 40 mg of propranolol is the most effective; the combination of a novokainamid (1 g) to propranolol is a little less efficient. Antiarrhythmic means (see) reasonable to combine with reception under language 5 mg of Seduxenum or 0,5 mg of Phenazepamum allowing to reduce excessive sympathoadrenal reaction.
At frequent attacks select drugs for constant use since no course treatment has preventive effect concerning paroxysms. Quinidine is most effective (on 0,2 — 0,5 g 4 times a day). In cases of bad portability of quinidine appoint novokainamid in the daily dose of 2 g divided into 4 receptions without night break. According to E. I. Chazov and V. M. Bogolyubov, the daily dose can be sometimes increased to 6 — 8?. Long reception of a novokainamid irrespective of a dose causes medicinal in a part of patients lupus erythematosus (see) in this connection regular control of blood on the maintenance of cells of a lupus erythematosus is necessary and it (is desirable) antinuclear antibodies. Reasonablly at insufficient efficiency of quinidine and a novokainamid or their bad portability to combine these drugs with blockers of beta and adrenergic receptors (e.g., anaprilin on 10 — 40 mg in each 6 hours). Inconvenience of use of all listed drugs — need of their quadruple reception without night break (only at the same time it is possible to maintain concentration in blood of medicinal substances at the sufficient level). In this respect much more conveniently reception of a kordaron (Amiodaronum), to-ry appoint within the first week 0,6 g a day, during the second — on 0,4 g and then about 0,2 g a day are constant. According to the same scheme and approximately in the same doses appoint delagil or plaquenil. Constant reception of delagil demands regular control of a condition of an eyeground (each 3 — 4 months). In nek-ry cases, especially in the presence of signs of an overload of the left auricle, sinus tachycardia and accurate communication of M. of ampere-second an exercise stress, constant administration of drugs of group of a foxglove is effective. At patients with the expressed disturbances of the psychoemotional sphere that is quite often observed at M. and., efficiency of therapy considerably increases at co-administration of psychotropic drugs in adequate doses. In some cases therapy by psychotropic drugs itself leads to disappearance of attacks for the nek-ry period (sometimes for years) or in any case to their urezheniye, shortening and easier current. At very frequent and long attacks it is sometimes reasonable to translate paroxysmal M. and. in a constant form. For this purpose the next attack is not stopped, and appoint to the patient drugs of group of a foxglove. However to achieve M.'s transition and. in a constant form it is possible not always.
At an atrial flutter all listed above means, and also their combinations give very variable effect. The combined treatment by cardiac glycosides and Isoptinum (on 80 mg 4 times a day) often allows to achieve if not the termination of attacks then their urezheniya, shortening and smaller pulse rate during attacks thanks to what they are much better had.
At a constant form M. and., if treatment is required, choose one of two options of therapeutic tactics depending on circumstances: recovery of a cordial rhythm or constant use of cardiac glycosides as main medicine. Apply to normalization of a rhythm countershock (see); at strict execution of all requirements it is almost safe for life of the patient. Indisputable advantage of a countershock is presence of the doctor and a possibility of electrocardiographic control at the time of recovery of a rhythm. Apply quinidine much less often: in the first day — in a dose of 0,05 — 0,1 g for check of portability of drug, for the second day — the first reception of 0,4 g and then on 0,3 g each two hours to the general dose of 1,6 g, for the third day — five receptions on 0,4 g every two hours to the general dose of 2 g etc. It is undesirable that the daily dose of quinidine exceeded 3 g since complications, including heavy are possible, up to fibrillation of ventricles of heart.
To make attempts of normalization of a rhythm malotselesoobrazno at M. and., observed more than 2 years, at a cardiomegaly and especially an atriomegaly and also when M. and. it was shown in the form of paroxysms earlier. In all similar cases, as a rule, quickly recurs disturbance of a rhythm therefore it is more correct to appoint to the patient one of cardiac glycosides in the dose necessary for transfer of a ciliary tachyarrhythmia in a bradyarrhythmia. If it is impossible to appoint drugs of a foxglove in the dose sufficient for a necessary urezheniye of speed cordial reduction, in addition appoint small doses of blockers of beta and adrenergic receptors or verapamil.
Various options of electric cardiac activation at M. and. did not find broad application in connection with small efficiency yet; however in this direction intensive researches are conducted.
the Forecast depends first of all on what disease caused arrhythmia (e.g., at rheumatic mitral heart diseases M.'s emergence and. quickly leads to development of heart failure; the same is observed at the diseases which are followed by extensive and severe damages of a cardiac muscle — krupnoochago a vy myocardial infarction, a congestive cardiomyopathy). On the contrary, in the absence of heart diseases and a top functional condition of a left ventricle the forecast in most cases quite favorable.
See also Arrhythmias of heart .
Bibliography Volumes L. and Volumes Il. Disturbances of a heart rhythm, the lane with bolg., Sofia, 1976; Chazov E. I. and Bogolyubov V. M. Disturbances of a heart rhythm, M., 1972, bibliogr.; Shestakov S. V. Ciliary arrhythmia (blinking and atrial flutter), M., 1951, bibliogr.; Watanabe Y. Dreifus L. S. Cardiac arrhythmias, N. Y., 1977.
V. A. Bogoslovsky.