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Abstract: An elderly male patient with a history of hypertension, diabetes mellitus, and coronary heart disease presented to the emergency room with “sudden onset of panic attacks for 3 hours” without significant chest tightness, chest pain, or dizziness. After comprehensive treatment with amiodarone hydrochloride injection and low-molecular-weight heparin calcium injection, the patient’s symptoms improved and the panic disappeared, and the ECG monitor showed normal heart rate.
Basic information】Male, 63 years old
Disease Type】Paroxysmal atrial fibrillation
Hospital】Qilu Hospital of Shandong University
Date of consultation】May 2022
Treatment plan】Medication (amiodarone hydrochloride injection, low molecular weight heparin calcium injection)
Treatment period】5 hours of outpatient treatment, review every six months
Treatment effect] The patient’s symptoms improved, the panic disappeared, and the ECG monitor showed normal heart rate
I. Initial consultation
Mr. Sun, 63 years old, visited the emergency department for “sudden onset of panic for 3 hours”. He had a history of hypertension, diabetes mellitus and coronary heart disease, with no obvious chest tightness, chest pain, dizziness, nausea and vomiting. He felt arrhythmia on his own pulse, and his panic symptoms did not ease after resting, so he visited the emergency department. The patient had a heart rate of 148 beats/min, blood pressure of 138/78 mmHg, clear consciousness, coarse breath sounds in both lungs, no obvious dry and wet rales were heard, absolute arrhythmia, varying intensity of the first heart sound, no pathological murmur was heard in each valve auscultation area, abdominal softness, no pressure pain and rebound pain, and no swelling of both lower limbs. Based on the patient’s symptoms and physical examination, an episode of atrial fibrillation was considered, and the perfect electrocardiogram suggested paroxysmal atrial fibrillation.
II. Treatment history
The patient denied a history of hyperthyroidism, and there were no contraindications to the use of medication in laboratory tests. The patient and his family were informed of his condition, and he could be considered for conversion therapy, with options such as electrical cardioversion, drug conversion and radiofrequency ablation surgery. At present, the patient’s vital signs were stable, there was no indication for acute electrical cardioversion treatment, and this was the first episode, so radiofrequency ablation surgery was not needed for the time being. The patient and his family agreed. So, he was given electrocardiographic monitoring, and amiodarone hydrochloride injection was given by static push, and then the drug was given by slow micropump injection, and low molecular weight heparin calcium injection was given by anticoagulation. During treatment, the patient’s nervousness was calmed, and common risk factors for AF were patiently explained to the patient and family members, including hypertension, diabetes, obesity, hyperthyroidism, family history of AF, etc. Common symptoms included panic, shortness of breath, weakness, chest tightness, chest pain, etc. Serious complications included cerebral embolism, myocardial injury, heart failure, etc. Measures for daily prevention and emergency treatment at home were also introduced. The patient’s symptoms basically disappeared after 5 hours of drug treatment, and the electrocardiogram was normal on recheck, and he was discharged from the hospital.
III. Treatment effect
After about 3 hours of drug treatment, the patient’s symptoms improved and the panic disappeared, and the ECG monitor showed sinus rhythm, i.e., normal heart rate, indicating that the conversion was successful. The patient itself was a first time attack and had a mild condition, and basically no further paroxysmal atrial fibrillation occurred after the trigger was removed. This treatment also indicates that drug therapy is the optimal solution for this patient with stable vital signs at this time. The patient was instructed to review every six months.
IV. Notes
The patient’s discomfort disappeared after successful transfer and there were no other abnormalities, and I was happy inside to see the patient recovered. Once again, I communicated with the patient and his family about his condition, combined with his other chronic diseases, and explained that after leaving the hospital, he needed to have a low-salt, low-fat, diabetic diet, quit smoking and drinking, exercise moderately, control his weight, and avoid staying up late and being emotionally agitated. At the same time, continue to take medication regularly, pay attention to monitoring blood pressure, blood sugar and blood lipid levels, and review every six months. If you feel chest discomfort, seek medical attention at any time, and consider anticoagulation to prevent thrombosis and radiofrequency ablation for frequent episodes of atrial fibrillation.
V. Personal insight
When paroxysmal atrial fibrillation occurs in patients, most of them will have panic, shortness of breath, weakness, chest tightness, chest pain, dizziness, syncope and other uncomfortable symptoms, which are often accompanied by anxiety and fear. Physicians should reassure patients while actively treating them with medication, explain in detail the disease, mechanism and treatment plan, so that they can have a clear understanding of the disease and thus actively cooperate with treatment. Early treatment is based on drug diversion, but before applying diversion therapy, it is necessary to assess whether the patient has any contraindications to the application of amiodarone hydrochloride injection, taking into account the patient’s past medical history and auxiliary examinations. If there is no contraindication, pharmacological diversion can be considered. If contraindications exist, anticoagulation and heart rate control drugs should be given to relieve symptoms and prevent complications. If drug diversion therapy is ineffective and transforms into persistent atrial fibrillation, heart rate control and anticoagulation therapy are required, followed by assessment of the need for electrical cardioversion and radiofrequency ablation surgical treatment. The entire treatment process should be timely communication with the patient and family members about the condition and treatment plan, explaining the pros and cons, and joint decision-making between the doctor and patient.