Chronic atrial fibrillation is a longstanding chaotic and irregular atrial arrhythmia. Prevalence increases progressively with age.
Patients frequently have co-existing cardiac or non-cardiac conditions, such as hypertension, coronary artery disease, valvular disease, heart failure, obesity, and sleep apnoea or pulmonary disease.
Causes significant morbidity (e.g., palpitations, dyspnoea, angina, dizziness or syncope, and features of heart failure, tachycardia-induced cardiomyopathy, or stroke) and death. Many patients are asymptomatic or have symptoms that are less specific for cardiac arrhythmias, such as mild dementia or silent strokes.
ECG shows absent P waves, presence of fibrillatory waves, and irregularly irregular QRS complexes.
Treatment strategy depends on the severity of symptoms, the duration of AF, and the presence of comorbid conditions. Treatment involves correction of the abnormal rate, or rate plus rhythm, along with anticoagulation in high-risk patients.
Risks and benefits of a chosen therapy, such as rate control or rhythm control strategies utilising beta-blockers, calcium blockers, digoxin, anti-arrhythmic agents, catheter-based or surgical ablation for pulmonary vein isolation and left atrial substrate modification, pacemakers, and ablation of the atrioventricular node need to be weighed based on multiple clinical factors to optimise patient outcome.
Atrial fibrillation (AF) is a supraventricular tachyarrhythmia. It is characterised by uncoordinated atrial activity on the surface ECG, with fibrillatory waves of varying shapes, amplitudes, and timing associated with an irregularly irregular ventricular response when atrioventricular conduction is intact.
History and exam
Key diagnostic factors
- presence of risk factors
- irregular pulse
Other diagnostic factors
- shortness of breath
- chest pain
- elevated jugular venous pressure
- murmur or gallop rhythm
- decrease in mentation or listlessness
- coronary artery disease
- congestive heart failure
- advancing age
- diabetes mellitus
- rheumatic valvular disease
- alcohol abuse
- male sex
- presence of other arrhythmias
- thyroid disease
- autonomic neuronal dysfunction
- obesity and obstructive sleep apnoea (OSA)
- caffeine abuse
- working long hours
- excessive exercise
1st investigations to order
- thyroid profile
- serum urea and electrolytes (including serum magnesium)
Investigations to consider
- serum transaminases
- prolonged ECG monitoring
paroxysmal or persistent AF: haemodynamically unstable
paroxysmal or persistent AF: haemodynamically stable
Arti N. Shah, MS, MD
Assistant Professor of Medicine
Mount Sinai School of Medicine
ANS declares that she has no competing interests.
Bharat K. Kantharia, MD, FRCP, FAHA, FACC, FESC, FHRS
President, Cardiovascular and Heart Rhythm Consultants
Clinical Professor of Medicine
Icahn School of Medicine at Mount Sinai
Attending and Consultant Cardiac Electrophysiologist
Mount Sinai and New York Presbyterian Hospitals
BKK declares that he has no competing interests.
Andrew R.J. Mitchell, BM, MD, FRCP, FESC, FACC
Jersey General Hospital
ARJM declares that he has no competing interests.
Diwakar Jain, MD, FACC, FRCP, FASNC
Professor of Medicine (Cardiology)
Westchester Medical Center
DJ declares that he has no competing interests.
Konstadinos Plestis, MD, FACS
Department of Cardiothoracic Surgery
Mount Sinai Medical Center
KP declares that he has no competing interests.
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- Atrial tachycardia with variable AV conduction
- Atrial fibrillation: diagnosis and management
- 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS)
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