A 67-Year-Old Man With Hypertension, (non valvular) Atrial

Fibrillation, and Embolic Stroke

A. Novrianto1, R. Wardani2 , S. Salsabila3
1
Faculty of Medicine, University of Brawijaya, Malang, Indonesia;
2
Medical Intern Hasta Brata Hospital, Batu, Indonesia;
3
Faculty of Medicine, University of Brawijaya, Malang, Indonesia

ABSTRACT
Background
Atrial fibrillation is a supraventricular tachyarrhythmia characterized by uncoordinated atrial
activation with consequent deterioration of mechanical function. Atrial fibrillation is the most
common sustained cardiac rhythm disturbance. Hypertension and AF often coexist. In the ARIC
study (Atherosclerosis Risk in Communities), hypertension was the main contributor to the
burden of AF, explaining 20% of new cases. Among patients with established AF, hypertension
is present in 60% to 80% of individuals.
Atrial fibrillation increase mortality and morbidity rate, including stroke, heart failure and
decrease patients’ quality of life. Patients with atrial fibrillation are most likely to develop stroke
5 times higher than patients without it. The relationship between AF and stroke also fails Hill’s
criterion of specificity. If AF causes thromboembolism, it should be specifically associated with
embolic strokes. There does appear to be an especially strong association between AF and
embolic strokes.

Case Illustration and Discussion

A 67-year-old male came to ER after falling out of bed with chief complaint of sudden weakness
of the left part of the body. It is found that he has speech difficulties and facial asymmetry
without headaches, nausea, or vomiting. Patient has high blood pressure controlled with
candesartan and furosemide.
From physical examination, it is found that the blood pressure is 170/100 mmHg, there’s a
paresis of nervous VII sinistra, paresis of nervous XII UMN type, and the manual muscle test
(MMT) scoring of the upper and lower left limbs is only 2. ECG examination shows atrial
fibrillation. Head CT scan shows acute infarction of the external capsule dextra & frontotemporal
lobe dextra. Chest X-Ray shows cardiomegaly with dilated aorta.

Discussion
Hypertension is the most important modifiable risk factor for AF, in this patient found that he
had the history of hypertension and his ECG examination shows an atrial fibrillation. Once the
hypertension occurred, it predisposes to AF, even if BP control improves later, like in this patient
that controlled with candesartan and furosemide. In the Framingham Heart Study, over 15-year
follow-up, more effective pharmacological reduction of BP has not translated into a noticeable
reduction in AF occurrence in hypertensive patients. Hypertension is also a risk factor for AF
recurrence, and where rhythm control is the chosen strategy for paroxysmal or persistent AF,
effective hypertension management prolongs the AF-free period. Antihypertensive drugs that
inhibit the RAAS might be preferred to reduce the risk of AF, but evidence is not yet conclusive.
Thus, an immense area is open to research.
AF is associated with a 5-fold increase in the risk of stroke, a 3-fold increase in the risk of heart
failure (HF), and a 2-fold increase in the risk of mortality. It is come true with this patient who
came with chief complain related to stroke and its head CT scan shows acute infarction.
Two, it is unknown whether lower BP targets may be associated with a lower risk of
cerebrovascular, cardiac, and hemorrhagic complications in patients with established AF. Three,
current hypertension guidelines, including the recently released American guidelines, do not
recommend more aggressive BP targets for prevention of AF, as well as in patients with
established AF, although such suggestion may sound reasonable on the basis of epidemiological
evidence. Four, In a recent European Consensus Document, highlighted numerous settings for
future studies. One, it would be important to refine the individual prediction of AF in
hypertensive patients in sinus rhythm. For example, studies in large cohorts should investigate
the impact of a blunted day–night BP rhythm as potential predictor of AF. Two, it is becoming
increasingly important to identify, through remote ECG monitoring, the patients with silent AF
who might benefit from an anticoagulant therapy because of their higher risk of stroke and
death.170–172 In this context, the role of hypertension as a single independent predictor of
cerebrovascular events in patients with apparently lone AF should be clarified. Ad hoc designed
intervention trials should also define an optimal BP target, which may balance the risk of
thrombotic and hemorrhagic complications in anticoagulated patients with AF, as well as the risk
of AF recurrence after catheter ablation.

Results from several randomized clinical trials of antithrombotic therapies have shown that
adjusted-dose warfarin reduces first or recurrent stroke by about 60% compared with placebo.
When patients with nonvalvular AF are anticoagulated, the odds against ischaemic stroke and
intracranial bleeding favour an INR between 2.0 and 3.0. Acetylsalicylic acid is less efficacious
than warfarin in AF patients, reducing the risk of stroke by about 20%. Therefore, this
antiplatelet agent should be used only for AF patients at low risk. Anticoagulation is the current
treatment modality in AF patients at high or intermediate risk, i.e. patients with history of
transient ischaemic attack or stroke, those aged >65 years, those with a history of hypertension,
diabetes, heart failure or structural heart disease, valvular disease or significant systolic
dysfunction. The benefit of dual antiplatelet regimens in AF patients is unknown, and combining
antiplatelet agents with different mechanisms of action is an important topic for future
investigation.

It has been shown that a decrease of 10 mmHg in systolic blood pressure is associated with
approximately a 35% lower risk of stroke (15–17). Thus, the aggressive treatment of
hypertension to existing targets (18) is a practical strategy to further reduce stroke in patients
with AF.
Antihypertensive therapy reduces not only the risk for stroke but also the risk for atrial
fibrillation.
Conclusion
In this case, the patient with history of hypertension showed stroke symptoms with ECG of atrial
fibrillation. Based on existed theory, hypertension increase the risk of atrial fibrillation, while
atrial fibrillation increase the rate of embolic stroke related mortality and morbidity.
Keywords
Atrial Fibrillation, Stroke, Embolic, ECG

Prinsip AF;
Valv/non
Non valv  paroxysmal (<48 jam convert sinus baik spontan atau drugs)
>48jampersisten
>1th long standing
>1th dan sudah drugs utk konversi jd sinus permanen AF

Kontrol rate, rhytm,

Usaha kontrol rhytm b blok, ccb, amiodarone
Antikoagulan

Valvular  warfarin, vit k

Non valv
NOEC (rivaroxaban, etc)