Download ATRIAL FIBRILLATION CARDIOVERSION FOLLOWING

ATRIAL FIBRILLATION CARDIOVERSION FOLLOWING ACUPUNCTURE: CASE REPORT
RUNNING HEAD: ACUPUNCTURE CARDIOVERSION OF ATRIAL FIBRILLATION
ABSTRACT
Atrial fibrillation (AF) is the most common arrhytmia and it stands an independent risk
for serious events. Acupuncture has been growing in popularity in the West and there
are reports of its potential benefits in treating AF. We report of a 57-year old man who
was admitted after having an allergic reaction to amiodarone administered to treat
paroxysmal AF with fast ventricular response. Cardioversion with intravenous
propafenone was uneventful. Before an attempt of electric cardioversion he was
treated with acupuncture as additional therapy to peroral propafenone. Both
immediate cardioversion to sinus rhythm and no paroxysmal AF during 30 days period
were recorded after acupuncture treatment consisting of 10 treatments during 30 days
period.
KEYWORDS: acupuncture, atrial fibrillation
INTRODUCTION
Atrial fibrillation (AF) is the most common arrhythmia, occurring in 5,5 % in the overall
population (1). It confers an independent risk for stroke and death and, if left
untreated, it has a 30 day mortality of 24 %. Therapeutic approaches are aimed at
control of ventricular response, prevention of thromboembolic incidents and
restoration of sinus rhythm. For the latter they include pharmacologic and
nonpharmacologic cardioversion (2).
Acupuncture as a therapy has been used in management of numerous conditions in
Chinese traditional medicine for thousands of years. In recent decades it has grown in
popularity in Western countries and much attention is being given to research on its
efficacy and safety. There have been reports on successful management of paroxysmal
supraventricular tachycardia, hypertension and chest pain and results of a study
published in 2011 indicated that acupuncture might be efficient in preventing
recurrence after cardioversion of AF (3). More recently a study protocol for a
randomized controlled trial aimed at investigating antiarrhythmic effects of
acupuncture in persistent AF has been published (4).
We report a case of sinus rhythm restoration in a episode of paroxysmal AF following
acupuncture treatment.
PATIENT INFORMATION
A 57-year old caucasian male was brought to our emergency department (ED)
following an allergic reaction (flushing, rash on chest and drop in blood pressure to
90/60 mmHg) to intravenous (i.v.) amiodarone administered by the Emergency
Medical Service (EMS) in order to treat atrial fibrillation. Upon admission he was
anxious and complained of palpitations.
He had a history of palpitations and experienced several episodes of irregular heart
rhythm following lack of sleep or periods of work related stress. He had arterial
hypertension for two years and was regular in taking his prescribed medication ( 5mg
ramipril and 5mg amlodipine). There were no serious disease and cardiovascular
emergencies in his family.
His symptoms started 6 hours before coming to the EMS, when he noticed
palpitations. An ECG in the EMS showed a AF with fast ventricular response (cp>
125/min). His blood pressure (BP) was 180/110 mmHg and physical examination
showed no abnormalities other than irregular heart rhythm on auscultation. He was
administered 300 mg Amiodarone in 250 mL 5% dextrose solution and in a matter of
minutes had a drop in BP, a rash appeared on his chest, and he complained of
flushing. Amiodarone was stopped and 150 mg propafenone in 250 mL 5% dextrose
solution i.v. was admistered as an alternative. This attempt at cardioversion was
unsuccessful and the patient was transferred to our ED.
CLINICAL FINDINGS
Upon arrival to our ED he was agitated and complained of palpitations. His physical
examination findings were unremarkable other than irregular heart rhythm on heart
auscultation.
DIAGNOSTIC ASSESMENT
His blood pressure was 130/80 mmHg , pulse above 125/min, pulse oximeter showed
98% oxygenation. His BMI was 29.2 kg/m2, body temperature 36.7°C.
ECG showed atrial fibrillation with an average ventricular response of 107 bpm. He had
a left electrical axis and left anterior fascicular block.
There were no signs of accessory electrical conduction pathway in electrocardiogram.
There were no radiological or clinical signs of cardiac decompensation and we ruled
out acute coronary or pulmoembolic syndrome.
We performed both transtoracic and transoesophageal echocardiography which
showed structurally normal heart with normal heart cavities and good systolic function
of the left ventricle , with no visible thrombus.
Patient was on telemetry monitoring during the index hospitalization.
After ruling out immediate and life-threatening causes, such as cardiac ischemia,
congestive heart failure (CHF), and pulmonary embolism (PE), other possible causes of
paroxysmal AF were considered. The common causes of atrial fibrillation are well
known and undertaken diagnostic tests revealed no underlying structural heart
disease, thyrotoxicosis was excluded and there were no electrolyte disorders (common
causes of atrial fibrillation are listed in Table 1.)
Table 1 Etiology of Atrial Fibrillation
Cardiac
Ischemic heart disease
Non-cardiac
Pulmonary embolism
Valvular disease
Idiopathic
Hypertension
Medication noncompliance
Congestive heart failure
Thyroid disease
Sick sinus syndrome
Holiday heart syndrome
Pericarditis
Medication use
Infiltrative heart disease
Electrocution
Cardiomyopathy
Other pulmonary disease
Cardiac surgery
Chest trauma
Ischemic heart disease
Pulmonary embolism
Myocarditis
Hypokalemia ,
Hypomagnesemia
Congenital heart disease
Hypothermia
THERAPEUTIC INTERVENTIONS
According to AF treatment guidelines and based on our patient workup results, we
decided for rhythm-control strategy rather than rate-control strategy since paroxysmal
FA lasted less than 48 hours. Propafenone was prescribed in a oral dose of 150 mg
twice a day, bisoprolol 2,5 mg in the morning and standard thromboprophylaxis with
nadroparine 0,8 ml subcutaneusly once a day. A betablocator was excluded from
therapy due to AF with bradycardic ventricular response (cp<60/min) and a drop of
arterial blood pressure to 105/75mmHg.
The patient was very anxious and experienced palpitations, therefore we decided to
treat him with acupuncture before performing a transoesophageal ultrasound. He was
scheduled for electrocardioversion for the upcoming day.
Patient was stimulated bilaterally with acupuncture needles (Dong-bang acupuncture
needle, size(Width) 4.1"(10.5cm); Pyonex-small; Seirin, Japan) in three acupuncture
points ( HT-7, ST-36 and PC-6) Manual stimulation of the acupuncture point was
performed until „De-Qui“ effect (sensation of numbness, distension, or electrical
tingling at the needling site) was obtained and then needles were left for 25 minutes.
There was instant drop of ventricular response rate during treatment and two hours
after acupuncture therapy cardioversion to sinus rhythm occurred. There was no
significant drop in arterial blood pressure during or after acupuncture therapy.
We decided to provide him with additional ambulatory acupuncture therapy during 10
treatments every third day in addition to propafenone at peroral dose of 300 mg twice
a day. No anticoagulation was recommended due to CHA2DS2-VASC score of zero (0).
He was urged to minimize work related stress and keep diary of possible symptoms.
FOLLOW-UP AND OUTCOMES
On 24 hours Holter ECG performed after one month, sinus rhythm with median
frequency of 72/min was recorded. After 3 months of follow up, on a regular
cardiology control, ECG showed sinus rhythm and no palpitations or symptoms were
reported by the patient.
DISCUSSION
Atrial fibrillation (AF) is the most common clinical arrhythmia and represents a major
social and economical problem. The number of subjects with AF is constantly
increasing as a result of aging and improved survival in several cardiac and non-cardiac
diseases. Patients with AF are often symptomatic, have a reduced physical capacity
and are at high risk for thromboembolic events.
The possibility that acupuncture may exert its antiarrhythmic effect through an action
on the autonomic nervous system is a plausible hypothesis. Several clinical and
experimental reports have indicated that an imbalance of autonomic control
mechanisms due to either an increase in vagal or sympathetic neural activity directed
to the heart may favor the initiation and maintenance of AF episodes (5). In patients
who developed AF during Holter recordings signs of an increased vagal modulation of
sinus node have been frequently observed when sinus rhythm preceding AF initiation
was analyzed with spectral techniques (5). In addition, the antiarrhythmic effect of
flecainide has also been partially attributed to its antivagal action.
The application of acupunctural therapy in the Neiguan spot (PC-6) is well known in the
Western world for treatment of chest pain, sickness, and vomiting (6). The stimulation
of the Neiguan spot (PC-6) has also been utilized to treat palpitations and sensation of
fullness-tension in the chest (7). Experimental studies provided evidence that
electroacupuncture of Neiguan might produce a restoration of a physiological
sympathovagal balance as indicated by its effects on heart rate variability in men and
on hemodynamic parameters in anesthetized open-chest dog (8). It has also been
reported that bilateral acupuncturing of Neiguan spots might affect the firing rate of
the amygdala nucleus that exert a modulatory function on the autonomic nervous
system (9). It was previously observed that acupuncture matched the efficacy of the
most active available antiarrhythmic drug and that sham-acupuncture patients had an
AF recurrence rate similar to that of patients with no antiarrhythmic therapy (10).
It is plausible that acupuncture could enhance the antiarrhythmic efficacy of these
drugs by a combination effect on atrial electrical properties and autonomic
mechanisms.
CONCLUSION
Acupuncture treatment as a minimally invasive procedure appears to be a safe,
without any pro-arrhythmic effects, low cost and effective additional therapy in
patients with paroxysmal atrial fibrillation.
PATIENT CONSENT
The patient provided written permission for publication of this case report.
REFERENCES
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Rotterdam study. European Heart Journal. 2005;27(8):949-953.
http://eurheartj.oxfordjournals.org/content/27/8/949.long
2. Hersi A, Brent Mitchell L, George Wyse D. Atrial fibrillation: Challenges and
opportunities. Canadian Journal of Cardiology. 2006;22:21C-26C.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793882/
3. Lomuscio A, Belletti S, Battezzati P, Lombardi F. Efficacy of Acupuncture in
Preventing Atrial Fibrillation Recurrences After Electrical Cardioversion. Journal of
Cardiovascular Electrophysiology. 2010;22(3):241-247.
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on Drug Refractory Persistent Atrial Fibrillation: Study Protocol for a Randomized,
Controlled Trial. Evidence-Based Complementary and Alternative Medicine.
2015;2015:1-6.
http://www.ncbi.nlm.nih.gov/pmc/articles/pmid/25784948/
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homeostatic action of neiguan acupoint--role played by the cardial vagus nerve. J
Tradit Chin Med. 1988;8:271–276.
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point for prevention and treatment of cisplatin-induced nausea and vomiting. J Tradit
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Acupuncture. 1998;9:303–305.
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anesthetized open-chest dog. Jpn J Physiol. 2001;51:231–238.
https://www.jstage.jst.go.jp/article/jjphysiol/51/2/51_2_231/_article
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11:10 p.m.
HOSPITAL ED
ECG: atrial fibrillation
BP: 132/78 mmHg
CP: > 125/min
TTE: normal
12:00 a.m.
CARDIOLOGY DEPARTMENT
spontaneous conversion into
sinus rhytm
B
B+P+N
5 p.m.
onset of
symptoms
16th March 2015
AM PF .
.
10:50 p.m.
OUT OF HOSPITAL EMS
ECG: atrial fibrillation
BP: 180/110 mmHg
CP: 119/min
following AM : flushing
and drop in BP
scheduled
cardioversion
cancelled
TTE, TEE
17th
18th
10 a.m.
release
10:0 a.m.
CARDIOLOGY DEPARTMENT
billateral stimulation in three
accupuncture points –
instant drop in CP
Figure 1. Timeline of events. BP – blood pressure; CP – pulse frequency; TTE – transthoracic echocardiography; TEE –
transesophageal echocardiography; ED – emergency department; EMS – emergency medical service; AM – amiodarone
300 mg intravenously; PF – propafenone 300 mg intravenously; B – bisoprolol 2,5 mg orally; P – propafenone 150 mg
orally; N – nadroparine 0,8 mL subcutaneously