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workup was performed in this low-risk patient, although he history needs to be taken. Careful attention should be paid
was advised to follow up with his primary care provider on to any medications or substances that he or she may have
return home from the remote operational setting. ingested. Caffeine-containing beverages or supplements are
often overlooked because the patient may not consider these
in their medication history or because they are parts of their
Discussion
normal routine and may be forgotten. The provider should ask
This patient scenario presented several important clinical ques- specifically about coffee/tea, energy drinks, preworkout sup-
tions that do not have straightforward answers. First, and fore- plements, or “fat-burning” pills. Assessment of volume status
most, is the patient stable? Our patient’s pulse was in the 110s and hydration are also important contributing factors.
without indications of a rapid ventricular response. Further-
more, he did not have life-threatening hemodynamic instabil- Current American College of Cardiology/American Heart As-
ity caused by new-onset atrial fibrillation/flutter as his blood sociation (AHA) Task Force on Practice Guidelines and the
pressure was 110s/70s and he was without signs of shock. He Heart Rhythm Society guidelines suggest rhythm control in a
had no other clinical symptoms such as altered mental status, stable patient presenting with acute atrial fibrillation or flut-
ischemic chest pain, or clinical indicators or heart failure. In the ter (see section under management of acute atrial flutter). It
absence of such indicators, emergent cardioversion was not per- is extremely important to pay attention to portions of these
formed. He had a significant response to vagal maneuvers and guidelines that state “the ultimate judgment about care of a
IV hydration. This approach is supported by ACC/AHA/HRS particular patient must be made by the clinician and the pa-
guidelines that state that cardioversion is not appropriate for tient in light of all the circumstances presented by that patient.
rhythms that break. Had the rhythm persisted or the patient’s As a result, situations may arise in which deviations from these
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status deteriorated, cardioversion would have been a viable guidelines may be appropriate.” In a patient such as the one
11
treatment option because cardioversion is expected to be suc- presented, antiarrhythmic medications might have been given
cessful in young patients with a structurally normal heart where if not for further history taking, trigger identification, and risk
the duration of atrial fibrillation is short, less than 6 months stratification. Removing the stimulus and maintaining nor-
according to the AHA. Another consideration was the timing movolemia may be all that is required to treat young patients
11
of the patient’s symptoms with respect to onset of arrhythmia who are physically fit with low cardiac risk presenting acutely
and his past medical history for the purposes of risk stratifica- with identifiable substance-induced arrhythmia.
tion. It was also important to identify potential triggers since the
patient did not have a known underlying cardiac condition and References
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lar physically active lifestyle as required for his military duties. atrial flutter in the general population. Am J Cardiol. 2000;36(7):
The obvious triggers in this case were a trifecta of dehydration, 2242–2246 .
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ology of atrial fibrillation: a global burden of disease 2010 study.
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2
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so anticoagulation was not indicated in this case. For cases mias: an experimental study in dogs with review of literature.
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and exclusion of left atrial thrombus are important aspects of 7. Llach A, Molina C, Prat-Vidal C, et al. Abnormal calcium han-
management. While not performed for this patient, this case dling in atrial fibrillation is linked to up-regulation of adenosine
A2A receptors. Eur Heart J. 2011;32:721–729.
highlights a potential application for the use of portable ul- 8. Moustaka D, Mezzio M, Rodriguez B, et al. Guarana provides
trasound for assessment of cardiac structure and function as additional stimulation over caffeine alone in the planarian model.
well as exclusion of left atrial thrombus. In-hospital workup PLoS ONE. 2015. doi:10.1371/journal.pone.0123310
often includes echocardiography, which is becoming increas- 9. Mehta M, Jain A, Mehta A. Cardiac arrhythmias following intra-
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this study was that it used experienced Operators in a hospital 2018.
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In a healthy young patient with no predisposing cardiovascular diogr. 2011;12:665–670.
disease presenting with palpitations, a very thorough exposure

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