Rapid A. Fib or PACs?

Specialties Cardiac

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This may be a dumb questions but.. I had a patient that was in A. Fib and would have a couple beats that some nurses called PACs. I'm wondering if someone is in A. Fib could they have PACs or would this just be A.Fib with RVR for a few beats. Any clarification at all would be helpful. Thanks!!

Specializes in E/R, Med/Surg, PCU, Mom-Baby, ICU, more.

I'm also wondering why this pt is on Coreg rather then a selective beta blocker

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Specializes in Adult tele, peds psych, peds crit care.
You guys, I know you all are way too smart to let this one go over your head. All I'm doing is simply presenting a scenario to you. The question was asked if you could have PAC'S with Afib. The answer to that question is simply YES, you can as the original responder put it. I guess my only mistake was going into further detail. I keep forgetting everybody doesn't alway benefit from the who, what, when, where, and WHY. But I LOVE knowing WHY. It helps me to understand. All I'm trying to do is explain why, so there can be a full understanding of the reason the answer is simply "yes."

So there's another confusion about this? Okay. I thought I had explained it simple enough but....here goes. Once again, if the patient is in A-fib (ok, take that in for a sec) and then you see PAC's, not actually a part of the Afib b/c .....you have atrial contractions--- "How can you tell," you ask. PAC's with Afib are usually frequent enough to tell that the p wave is not just another quiver of the A fib b/c that atrial contraction is originating from the same foci so the p waves should look identical to each other. And to quote myself before someone else does so there's no confusion left hopefully (LOL), "PAC's are usually frequent enough to tell that the p wave is not just another quiver of the A fib" due to the pathophysiology like what I was explaining earlier about the heart's attempt to convert back into sinus. (See earlier posts) Now that we've establish that, this contraction IS NOT Afib--it can't be...there's a P WAVE involved. Still with me? Now... it's presumptuous to call it a "SINUS" beat b/c there would have to be a ventricular contraction to follow IMMEDIATELY after the p wave, because as you know, sinus beats are composed of both p waves and QRS complexes. A sinus beat is not what I interpreted out of the original post, only Afib and PAC's were mentioned. And that's the reason why those beats would not meet the criteria to be called sinus--simply put, no ventricular contraction, only a premature atrial contraction, which is why the nurse called it "Afib with PAC's."

So in a nutshell, you got Afib, then a few definite, true p waves->No longer just Afib---they are not followed by QRS complexes-->Cannot be sinus. So what do you all call this if it's not Afib with PAC's b/c ever since I learned rhythm interpretation that's what I've called them, that's what other nurses have called them, and the cardiologist.

Now I've answered alot of you guys' question, so how about answering one for me? Where are all of you working at and/or where have you worked and what is your discipline? This helps me to understand why this is such a hard concept to understand. B/c I find it hard to believe anyone working cardiology, or tele, or ER (or anywhere where telemetry is used) is struggling with this. Afib with PAC's is not your everyday kind of rhythm, but it's not so rare that it causes this kind of confusion normally, so I'm just trying to get some understanding so I can better relate. And then again, I can't help but feel there may be understanding of all of this that I am saying, but it's just more fun to watch just how far can we kick a dead horse b/c I'm at the point of ad nauseum (LOL) j/k. If you have anymore questions, please ask; that's how you learn. But if your intent is to be facetious, please I ask, go to the Nursing Humor Forum. My intent is to genuinely address the OP's question, and hopefully facilitate learning. Thank You.

You may choose to address these points or not address these points. No big deal. But to continue restating your points as if in a vacuum, condescension included, does not help you relate this concept to those of us who obviously "don't understand" as well as you.

At this point, I feel comfortable stating plainly that you are wrong on this concept. Since the first post, I've considered it often, considered your post, considered other posts and have come to the conclusion that your point that you can have pac's with/in/around/below/above or in a parallel dimension to afib is incorrect.

The simple appearance of a "p wave" (a faux p-wave because it only represents the last depolarization ((and very limited depolarization path)) of many that the AV node let thru) within irregular afib is not evidence of a premature atrial contraction. There are plenty of "p-waves" (the squiggly line between qrs complexes) that appear on a strip. They represent various attempts of the atria to depolarize in a singular fashion.. unfortunately, because the cardiac tissue is so irritable, it can't. Point A fires and can depolarize tissue over to point B but because point C also fired, the tissue around it hasn't repolarized yet meaning point A's wave can't travel any further... But D and E also fire at the same time, limiting how far the depolarization wave can travel for each of them as well. Those times that point A can depolarize all the way to point J before hitting presently depolarized tissue is when you get something that approaches physically looking like a p-wave in the midst of the squiggle.

A PAC (premature atrial contraction) is a depolarization initiated by a point other than the SA node. However, for this to be called a PAC and not MAT (multifocal atrial tachycardia) or WAP (wandering atrial pacemaker), it must occur as a single occurrence or multiple occurrences within the structure of a normal SA initiated rhythm. ie., SA...SA...SA..PAC...SA..PAC...SA...SA...

Additionally, to address another inaccurate point you made- there are no increases in pac's (since there are no pac's in afib) prior to conversion to NSR. As a matter of fact, I have never seen a conversion from afib to NSR that did not happen without a pause. That's necessary because the atria need a period of time to repolarize entirely. As such, there is no 'walk before you crawl' or 'reverse process' as you've described in a couple posts.

In light of my explanation and my comfort/confidence in my position, I'm still more than willing to consider POV's contrary to what I've said and willing to consider that I'm 100% wrong. Discussion promotes understanding. However, I won't continue to discuss this with someone who offers nothing but the same point over and over without any consideration of the contrarian points brought up and essentially says "I'm right because I'm right and you're just not getting it." I actually find that to be opposite the notion of facilitating learning that you expressed earlier...

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Specializes in Adult tele, peds psych, peds crit care.
I have a HH patient with a hx. of severe mitral insufficiency, Afib, and CHF.... in the past she had been on digoxin, but the doc had dc'd this early this year. She's still on Coreg, and Atacand.

The thing is, she is in a constant state of hypoxia... can never get an 02 sat above the low to mid 80's... often it's in the seventies... and this while on continuous 02 NC @ 2 L/min. I have to massage her arms and fingers for about 1/2 hour before I can FINALLY get a sat up to 90%. I've reported this to her doc time and again, but never get anywhere....

Agree with the others who state you should get an ABG. I've had pt's with sats in the low-mid 80's on the finger that registered a 96% on the ear! It would be a good idea to know exactly what the sat really is.

The use of Coreg is said to be better for the CHF patient because it's not only a Beta-1 blocker but a beta-2 (bronchioles- breath easier) and alpha-1 (vascular arterioles- lower bp) blocker. From what I've read, it's preferred first line over digoxin with CHF patients... fib/flutter folks without the chf history still apparently respond to dig better.

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Specializes in CCU/CVU/ICU.
You may choose to address these points or not address these points. No big deal. But to continue restating your points as if in a vacuum, condescension included, does not help you relate this concept to those of us who obviously "don't understand" as well as you.

At this point, I feel comfortable stating plainly that you are wrong on this concept. Since the first post, I've considered it often, considered your post, considered other posts and have come to the conclusion that your point that you can have pac's with/in/around/below/above or in a parallel dimension to afib is incorrect.

The simple appearance of a "p wave" (a faux p-wave because it only represents the last depolarization ((and very limited depolarization path)) of many that the AV node let thru) within irregular afib is not evidence of a premature atrial contraction. There are plenty of "p-waves" (the squiggly line between qrs complexes) that appear on a strip. They represent various attempts of the atria to depolarize in a singular fashion.. unfortunately, because the cardiac tissue is so irritable, it can't. Point A fires and can depolarize tissue over to point B but because point C also fired, the tissue around it hasn't repolarized yet meaning point A's wave can't travel any further... But D and E also fire at the same time, limiting how far the depolarization wave can travel for each of them as well. Those times that point A can depolarize all the way to point J before hitting presently depolarized tissue is when you get something that approaches physically looking like a p-wave in the midst of the squiggle.

A PAC (premature atrial contraction) is a depolarization initiated by a point other than the SA node. However, for this to be called a PAC and not MAT (multifocal atrial tachycardia) or WAP (wandering atrial pacemaker), it must occur as a single occurrence or multiple occurrences within the structure of a normal SA initiated rhythm. ie., SA...SA...SA..PAC...SA..PAC...SA...SA...

Additionally, to address another inaccurate point you made- there are no increases in pac's (since there are no pac's in afib) prior to conversion to NSR. As a matter of fact, I have never seen a conversion from afib to NSR that did not happen with a pause. That's necessary because the atria need a period of time to repolarize entirely. As such, there is no 'walk before you crawl' or 'reverse process' as you've described in a couple posts.

In light of my explanation and my comfort/confidence in my position, I'm still more than willing to consider POV's contrary to what I've said and willing to consider that I'm 100% wrong. Discussion promotes understanding. However, I won't continue to discuss this with someone who offers nothing but the same point over and over without any consideration of the contrarian points brought up and essentially says "I'm right because I'm right and you're just not getting it." I actually find that to be opposite the notion of facilitating learning that you expressed earlier...

Telehead, you're spot-on.

VicChic, your id says you're 22yrs old. if this is true, you're obviously new to the profession...and to telemetry. You're very eager and are obviously intelligent. You'll soon learn that trying to argue-down experienced cardiac nurses (like telehead) with nothing more than 'you dont get it...i'm right'...wont work. This may sound harsh, but lots of people/nurses/student nurses read these threads and it's important that we dont confuse them with mis-information. i would re-read teleheads post. She is right. even if you still think anyone who (correctly)disagrees with you 'doesnt get it'.

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Specializes in Hemodialysis, Home Health.
Agree with the others who state you should get an ABG. I've had pt's with sats in the low-mid 80's on the finger that registered a 96% on the ear! It would be a good idea to know exactly what the sat really is.

The use of Coreg is said to be better for the CHF patient because it's not only a Beta-1 blocker but a beta-2 (bronchioles- breath easier) and alpha-1 (vascular arterioles- lower bp) blocker. From what I've read, it's preferred first line over digoxin with CHF patients... fib/flutter folks without the chf history still apparently respond to dig better.

Aha ! That's the info I was looking for. So she should be doing as weel, if not better on the Coreg, then. hmmm....

OK.. so is it OK for me to ask for them to get an ABG, or would that be considered being just a bit pushy on my part? I'm really not sure of my boundaries yet in this field...

I keep assuming the docs are doing what they should be doing for these pts., but then I have to wonder sometimes. And I'm not sure when I should step in................ *sigh*

Anyway, THANK YOU for all your advice. :)

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Specializes in Hemodialysis, Home Health.
Jnette, also understand that there are going to be people who have chronic hypoxia and that's just the way they live life. Their bodies have adjusted and while not healthy, they maintain. Many people have O2 sats in the upper 80s chronically, especially with activity.

If the MD is o.k. with the hypoxia he should change the orders to allow for sats in the 80s, rather than you wasting your time trying to get her above 90.

Definately suggest an ABG. While ABGs just to get a pulse ox isn't appropriate all the time, in this case I would be very curious.

I agree, that if something could be done to maintain more optimal health, it should be tried.

I do believe she is chronic hypoxia, Tweety. But the recent increased episodes of SOB had me worried.. and yet her lungs are clear.

I guess I'll suggest an ABG just to be sure of everything, then if he feels her sats will never improve, I'll ask him to change the order to allow for those sats... now why didn't I think of that? :uhoh3:

See... that's why I come to you all.... my heros ! :D

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Didn't mean to make anyone feel like you "just don't get it." I'm just having a hard time understanding why haven't you seen Afib with occassional PAC's unless they were just assumed to be more fibrillations, which I could understand I guess. That's all.

Okay, I think now is a good time to say we agree to disagree. I never said I'm right because I'm just right and you're not. I offered knowledge that I have learned by working with cardiac pts and under the supervision of several cardiologists. That's it. Take it or leave it. The review was a nice refresher for myself actually. But I still stand by my responses 100% and so do the cardiologist I've worked with, b/c this is what they have taught me and the information is used by myself and my colleagues regularly. I don't have to argue what is fact already. Fact proves itself. So it's not "mis-information." There are professionals in health care using these very facts to treat pts. If you notice, I wasn't the only one who stated the possibility of Afib with PAC's. Once you have seen it, you don't ever deny its possibility. I'm just grateful for the experience, b/c as I'm learning it's not granted to everyone.

I'm just wondering why this is so unheard of to you, b/c it's really not that rare. Okay, not gonna beat that dead horse again (LOL).

Yes, it's true that I'm 22. I was wondering how long it was going to take before that came into the discussion. I'm young in nursing, but not new to it. I took prepatory classes for nursing school while still in high school and had credits towards my degree before graduating H.S. b/c it's offered like that if your serious about your training. Sort of a recruitment tool in the area, but it's training still. Before my cardiac nursing which consists of CCU and cardiac stepdown, I worked in the ER, med/surg ICU and in various outpatient centers. So very diverse considering the years in it.

So just b/c I'm young, doesn't mean I couldn't know what I'm talking about. Don't you think that's a lil' discriminatory towards age? You don't think the senior could ever learn from the freshman and vice versa? As much as healthcare changes, you bet. And I know this much is true. You might be surprised how many older nurses come to me for advice sometimes simply b/c I am young and they feel I would have the latest information on whatever the topic is b/c I have less to confuse it with from info that's now outdated b/c it's as old as I am, so to speak (LOL). And they to continue to ask even today, so that my let you know a little bit about my credibility. So may we all continue to expand our knowledge basis, both young and aged, in the ever changing world of healthcare, b/c as you more seasoned nurses know already: The only thing that's constant in nursing is that it changes...alot. We're in this together and whatever problems we have in nursing, we certainly don't solve anything by creating discord among each other, nor does the whole "aren't you 22?" arguement do much for dispelling the fact/opinion that Nurses eat their young which further contributes to a myriad of other issues in nursing. If I had a nickel for everytime someone tried to discredit my nursing knowledge just b/c it belonged to a 22 yo.... I probably could retire by age 23! But that's okay, you wouldn't be the first, and certainly not the last. Buh-bye! ;)

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Specializes in Combat Support Hospital; Geriatrics.

Sorry, but you can't have an atrial fib along with PACs. PAC's can lead to Afib ,however.

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Specializes in Adult tele, peds psych, peds crit care.
Didn't mean to make anyone feel like you "just don't get it." I'm just having a hard time understanding why haven't you seen Afib with occassional PAC's unless they were just assumed to be more fibrillations, which I could understand I guess. That's all.

Okay, I think now is a good time to say we agree to disagree. I never said I'm right because I'm just right and you're not. I offered knowledge that I have learned by working with cardiac pts and under the supervision of several cardiologists. That's it. Take it or leave it. The review was a nice refresher for myself actually. But I still stand by my responses 100% and so do the cardiologist I've worked with, b/c this is what they have taught me and the information is used by myself and my colleagues regularly. I don't have to argue what is fact already. Fact proves itself. So it's not "mis-information." There are professionals in health care using these very facts to treat pts.

I haven't seen Afib with occasional PAC's because, as I work through this and try to understand it, the rhythm doesn't exist.

I'm not trying to be confrontational. This is an open discussion seeking to answer the OP's question that has grown because of differing opinions. You stated previously that you love the how/why. I believe myself, Dinith88 and others have tried to describe, physiologically, the how/why afib with pac's is not possible, at least as I/we understand it right now. I've stated more than once that I'm open to where I might be wrong. Your responses have been, repeatedly, the same thing (ectopic beats without QRS complexes) backed with "that's what other nurses and cardiologists have told me". Additionally, within your explanation, you've stated things that simply aren't true (ie., a run of pac's indicate an attempt to convert to sinus).

What many of us have tried to do, as you state, is also 'offer knowledge that we have learned' with explanation in an effort to further everyone's knowledge, mine/ours included.

If you notice, I wasn't the only one who stated the possibility of Afib with PAC's. Once you have seen it, you don't ever deny its possibility. I'm just grateful for the experience, b/c as I'm learning it's not granted to everyone.

Actually, outside of the first responder, you are the only one. Everyone else has disagreed with your contention. As a fan of the old movie "12 Angry Men", I don't put any weight behind the number of people agreeing or disagreeing with me as evidence of the truth. But as others have added their responses, it does count towards building the knowledge base and contributing to the most likely answer. I suspect what you "saw" wasn't afib with pac's. Someone may have incorrectly interpreted it that way, but after hashing thru the physiology, it doesn't seem to hold much water.

Yes, it's true that I'm 22. I was wondering how long it was going to take before that came into the discussion. I'm young in nursing, but not new to it. I took prepatory classes for nursing school while still in high school and had credits towards my degree before graduating H.S. b/c it's offered like that if your serious about your training. Sort of a recruitment tool in the area, but it's training still. Before my cardiac nursing which consists of CCU and cardiac stepdown, I worked in the ER, med/surg ICU and in various outpatient centers. So very diverse considering the years in it.

So just b/c I'm young, doesn't mean I couldn't know what I'm talking about.

Don't you think that's a lil' discriminatory towards age? You don't think the senior could ever learn from the freshman and vice versa? As much as healthcare changes, you bet. And I know this much is true. You might be surprised how many older nurses come to me for advice sometimes simply b/c I am young and they feel I would have the latest information on whatever the topic is b/c I have less to confuse it with from info that's now outdated b/c it's as old as I am, so to speak (LOL). And they to continue to ask even today, so that my let you know a little bit about my credibility.

Nobody questions your credibility as a nurse. We're all (mostly?) nurses here. Some certainly have more knowledge than others in certain areas and some certainly have more experience than others. To be honest, you were the first to question the level of credibility, in an effort to "understand why this was such a hard topic for us (me?) to understand."

So may we all continue to expand our knowledge basis, both young and aged, in the ever changing world of healthcare, b/c as you more seasoned nurses know already: The only thing that's constant in nursing is that it changes...alot. We're in this together and whatever problems we have in nursing, we certainly don't solve anything by creating discord among each other, nor does the whole "aren't you 22?" arguement do much for dispelling the fact/opinion that Nurses eat their young which further contributes to a myriad of other issues in nursing. If I had a nickel for everytime someone tried to discredit my nursing knowledge just b/c it belonged to a 22 yo.... I probably could retire by age 23! But that's okay, you wouldn't be the first, and certainly not the last. Buh-bye! ;)

The vast majority of this discussion took place before the question of age ever came up. This isn't nurses eating their young. It is an honest attempt at discussion. As I've stated, I'm comfortable with my understanding on this topic and the process of hashing it out enhanced it. The value of discussion.

Don't ever stop asking questions and those people with the M.D. (or D.O.) after their names are right most of the time, but not every time.

You may have the last word, if you choose.... unless it can lead to further discussion! ;)

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Specializes in E/R, Med/Surg, PCU, Mom-Baby, ICU, more.

The use of Coreg is said to be better for the CHF patient because it's not only a Beta-1 blocker but a beta-2 (bronchioles- breath easier) and alpha-1 (vascular arterioles- lower bp) blocker. From what I've read, it's preferred first line over digoxin with CHF patients... fib/flutter folks without the chf history still apparently respond to dig better.

I did a looksy on Coreg and you hit the nail on the head. The use of beta blockers in CHF decreases mortality. In CHF the heart tries to compensate for low cardiac output by increasing its rate and contractions. In the long run this will cause the heart failure to get worse. Beta blockers stop this mechanism.

I was thinking about Coreg blocking beta 2 which would block bronchodilation.

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Specializes in Adult tele, peds psych, peds crit care.
I did a looksy on Coreg and you hit the nail on the head. The use of beta blockers in CHF decreases mortality. In CHF the heart tries to compensate for low cardiac output by increasing its rate and contractions. In the long run this will cause the heart failure to get worse. Beta blockers stop this mechanism.

I was thinking about Coreg blocking beta 2 which would block bronchodilation.

Andy, you are right. As I was typing the Beta 2 (bronchioles, breathe easier), I had one of those "wait a minute, that doesn't look right" moments but blew it off without thinking and kept typing. Thanks for catching that.

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Specializes in Telemetry, ICCU, Home Care, Psych/MRDD.

Do you have basic or advanced arrhythmia classes you can sign up to take? You can't have PAC's in A-fib. A-fib can speed up to over 100---hence the RVR or slow down to a controlled rate (below 100). You can have lots of PAC's especially in lungers and sometimes it's a pretty strong indicator they're going to go into A-fib. There's also multi-focal atrial tach which can look like PAC's because you actually have a P.

Steelcity may have been thinking of Ashmon's Phenomenon which looks like PAC's in the middle of Atrial Fib.

Atrial Fib is a rhythm, PAC's are an incidental in a sinus rhythm.

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