Atrial fib. with PVC's?

SusanJean · Nov 29, 2004

Hello, to all! Can someone explain why a person in A. fib with ventricular response of 120 beat/min cannot have PVC's. I had a patient last night in this situation and they had what appeared to be a 6 beat run of V-tach; however, I was told that a person in A. Fib can not have PVC's.
Thanks in advance!

That's a new one for me too...I'd like to hear more.

Dinith88 · Nov 29, 2004

Whoever told you that didnt know what they were talking about.

Dinith88 · Nov 29, 2004

Should've added...

In a-fib, you'll occaisionally see runs of abberant beats that mimic pvc's/vt (wide, bizarre, different qrs-complex morphology, etc.). I think the term is Ashman's phenomena. (because this abberant conduction does not have a ventricular origin, it's a more-or-less benign finding)

There're certain ways to distinguish this from v-tach (easier to do if 12-lead captures it). However, it's not very common and until this can be confirmed, it's best to assume they're pvc's.

BUT, ashmans phenomena is the exception, and if you're unsure, call it v-tach.

AND, it would be piss-poor practice to assume that all pvc's in a-fib are ashmans beats. ...

Am i off track? I guess the point is:---- Yes, PVC's definitely can occur while a heart is in a-fib-------.

TiffyRN, BSN, PhD · Nov 30, 2004

Gosh, this gives me good memories of working cardiac. There is an argument amongst the cardiac folks about this. Not so much can there be V-tach in the middle of A-Fib (most of the docs I worked with agreed there can be though they recognized that it could also be Ashman's phenomenon). There were those who said there cannot however be any PVC's in A-fib because by definition they are premature and there is no way of determining if a beat is premature in A-fib since it is irregular. Their argument was that there was no way of determining if the abberrant beat was a premature vent. contraction or an vent. escape beat. On the tele floors where they were sticklers about this we called such a rhythm "A-fib with V.E. (ventricular ectopy)".

Gosh, I used to love that aspect of cardiac nursing.

Dinith88 · Nov 30, 2004

Gosh, this gives me good memories of working cardiac. There is an argument amongst the cardiac folks about this. Not so much can there be V-tach in the middle of A-Fib (most of the docs I worked with agreed there can be though they recognized that it could also be Ashman's phenomenon). There were those who said there cannot however be any PVC's in A-fib because by definition they are premature and there is no way of determining if a beat is premature in A-fib since it is irregular. Their argument was that there was no way of determining if the abberrant beat was a premature vent. contraction or an vent. escape beat. On the tele floors where they were sticklers about this we called such a rhythm "A-fib with V.E. (ventricular ectopy)".
Gosh, I used to love that aspect of cardiac nursing.

THats a good point tiffy. But dont you think It's kinda splitting hairs? Obviously, it cant be called 'premature' if the atria arent in a sinus rhythm...however, these beats have the same etiology and are as 'significant' in a-fib as they are in any other rhythm. And you stated that 'most' of the doc's you worked with agreed that v-tach can occur in a-fib...i'd be VERY afraid of the doc's who werent in agreement with these guys...hopefully they not cardiologists

Anyway, i think 'a-fib with ventricular ectopy' is a good way of 'naming' such a rhythm...but i would also warn newer nurses not to jump to conclusions regarding ashmans. If it looks like VT...consider it just that until proven otherwise.

Good Post Tiffy!

Crumbwannabe · Dec 1, 2004

Obviously in A-Fib all the stimuli are not getting through the His pathway, (thank goodness), but if you really want to catch hell from a cardiologist, try to define anything without a 12 lead. It's either A-fib or flutter, SVT, or ventricular origin. Period, with a lot of docs, anyhow. (Just report 'it appears to be x, y or z, Sir.')

There can be unknown abnormal pathways, BBB at a given millisecond interval which mimics VT. Antiarrythmics can of course be proarrythmic given the right circumstances, and you never know what those little action potentials are going to do. Wide QRS can be retrograde depolarization, blah,blah....you know all of this. I'm just throwing in my 2 cents worth from one who has been yelled at a time or two for being 'Dr. Nurse'.

Dinith88 · Dec 2, 2004

Just was re-reading my prior posts and wanted to clarify what i mean by pvc's being possible with a-fib....

PVC's happen when the ventricle/ventricles become irritated, etc. When a PVC happens, it does so irregardless of what the atria are doing. The atria could be sinus, a-fib, pat, etc... the ventricles dont care. Now, if it happens during sinus, it is called 'premature' because it happens withought 'listening' to the atria, and thus contracting out of synch.

So, if a ventricle becomes irritated and fires while someone's atria are fibrillating, you cant (obviously) call it 'premature'...

However, a PVC is a PVC is a PVC no matter what the rhythm of the atria, and are just as significant (or not) regardless.

As far as talk about Ashmans, retrograde this-and-that, blah blah, etc...thats all fluff.

PVC's can and do occur in a-fib...

Crumbwannabe · Dec 2, 2004

Just was re-reading my prior posts and wanted to clarify what i mean by pvc's being possible with a-fib....
PVC's happen when the ventricle/ventricles become irritated, etc. When a PVC happens, it does so irregardless of what the atria are doing. The atria could be sinus, a-fib, pat, etc... the ventricles dont care. Now, if it happens during sinus, it is called 'premature' because it happens withought 'listening' to the atria, and thus contracting out of synch.
So, if a ventricle becomes irritated and fires while someone's atria are fibrillating, you cant (obviously) call it 'premature'...
However, a PVC is a PVC is a PVC no matter what the rhythm of the atria, and are just as significant (or not) regardless.
As far as talk about Ashmans, retrograde this-and-that, blah blah, etc...thats all fluff.
PVC's can and do occur in a-fib...

Is 'fluff' a term for abnormal conduction pathways and alteration of the action potential? Meaning I agree to an extent. There are only 3 basic dysrhythmias; SV, A-fib/flutter, or ventricular. Cardiac tissue does not become 'irritable', and antiarrythmics are not anti-itch creams . It is refractory period alterations and involves active and passive transport of ions. All the respect in the world to you, check out a good book on E/P testing. I suggest Foguros (sp?). He's really good, and a joy to read. And it has to be simple for me....

nowplayingEDRN · Dec 2, 2004

Is 'fluff' a term for abnormal conduction pathways and alteration of the action potential? Meaning I agree to an extent. There are only 3 basic dysrhythmias; SV, A-fib/flutter, or ventricular. Cardiac tissue does not become 'irritable', and antiarrythmics are not anti-itch creams . It is refractory period alterations and involves active and passive transport of ions. All the respect in the world to you, check out a good book on E/P testing. I suggest Foguros (sp?). He's really good, and a joy to read. And it has to be simple for me....

I think, from reading this thread, that the term "fluff" was used in place of the word hogwash.......When one states that the artia or the ventricles are irritable, it is to say that they are recieveing stimulus from more than one place (ie: normal electrcal pathway) in the tissue, such as in A-fib.....the atria would look very much like a bag of worms because the electrical stimulus is causing the atria to usually beat in excess of 200, hense the squiggley looking base line where a nice P wave should be, which does not effectively empty the atria and hense puts a pt at risk for clots if not treated immediately or within 48. After 48 hours and you have to treat the rhythm and rate before you can even consider cardioversion (minimizes the risk of breaking off a potential clot). I also agree that nothing should be confirmed without a 12 lead (ICU and ER experience talking now and the memory of a doc or 2 yelling...lol), yes you can have ectopic beats in A-fib/flutter. Yes, depending on how frequently the ectopy is occuring, it can be quite significant and yes, anti arrhythmics can, under certain circumstances have the exact opposite effect and creat a proble rather than correct it. When I first started nursing, I thought the ectopics looked like PVCs and then I took ACLS and talked with the cardiologists and learned that based on what is happening in the heart with A-fib/flutter, it can not be called a PVC because you do not have an actual P-QRS-T complex because of the disrhythmia. Now that I have rambled on and more or less repeated in dofferent words what everyone else basically said....I'll shut up now....LOL (I really need to get better and go back to work....LOL LOL LOL)

Dinith88 · Dec 2, 2004

Is 'fluff' a term for abnormal conduction pathways and alteration of the action potential? Meaning I agree to an extent. There are only 3 basic dysrhythmias; SV, A-fib/flutter, or ventricular. Cardiac tissue does not become 'irritable', and antiarrythmics are not anti-itch creams . It is refractory period alterations and involves active and passive transport of ions. All the respect in the world to you, check out a good book on E/P testing. I suggest Foguros (sp?). He's really good, and a joy to read. And it has to be simple for me....

1) my last post wasn't directed at yours, but i'll reply to your post..

2) Abnormal condution pathways are usually responsible for atrial dysrhythmias, not PVC's. That is the stuff of a different thread, like 'what causes svt or wpw, etc.'... so it's kinda irrelevant here

3) By 'Fluff', i meant that discussion of other sources of wide-bizarre complexes in a-fib is inconsequential to the origional question. the answer is 'yes..pvc's occur in a-fib'. Ashmans, abberant pathways, etc. is kinda like a different discussion..

4) You're mistaken with your '3 basic dysrhytmias'...Indeed, AFib/Flutter are both SV dysrhythmias..so actually there are only 2..atrial or ventricular (SV simply means the arrhythmia is occuring above the ventricles (ie in the atria)

5) Cardiac tissue DOES become irritable (can happen in more ways than one). a) have you ever pulled a SWAN and seen pvc's (happens all the time) because the catheter passes through and 'irritates' the Right ventricle b) ischemic insult obviously causes cardiac irritability... thats where MI related VT/VF comes from c)cardiac tissue can become irritable in electrolyte disturbances and cause pvc's. d) by 'irritable' i dont mean itchy, but your attempt at the humorous 'itch-cream' analogy was actually a good one...for instance lidocaine directly 'numbs' and sooths irritated heart muscle and lessens ventricular ectopy...

6)i'll stop short of picking your post completely apart because i have an awful record of getting my posts pulled for flaming...

7)ep book? I've worked with ep-docs for a number of years and am very familiar with arrythmias, their cause, and treatment.

8)I think you should re-read my previous posts because i'm not sure if you understood them..or perhaps you should get a simpler ep-book.

9) i apologize if you thought my last post was an attempt at bashing yours

Dinith88 · Dec 2, 2004

with A-fib/flutter, it can not be called a PVC because you do not have an actual P-QRS-T complex )

Thats a good point that Tiffy brought up as well. Yes, technically a PVC is only a 'P'VC if recorded while the atria are sinus. However, the point i was attempting to stress above the others is that when a PVC happens (for whatever reason), it happens despite what the atria are doing. Thus, when they happen in A-fib, you cant call them 'premature', BUT...they're still a pVC and (as you stated), they may or may not be 'significant'.

The other point was that wide, bizarre complexes that resemble PVC's can happen in a-fib (or any other rhythm). However, these are not as common as PVC's and are in some cases easily distinguishable without 12-lead. For example, Tiffy mentioned ventricular escape beats. These beats are readily identifiable because they're typically found in brady-dysrhythmias, or when an a-fib goes a bit slow(as in SSS)...and these 'escape beats' are usually regular and if you see a 'run' of them, they arent generally fast (junctional, excellerated junctional, idioventricular, etc.) (whereas PVC's can readily degenrate into vt/fib under certain circumstances.)

So...i still say that until proven otherwise, consider wide, bizarre complexes in a-fib "pvc's".

Maybe we should call them 'VC's and skip the 'P' part... :)