Summary
Definition
History and exam
Key diagnostic factors
- palpitations
- irregular pulse rate
- risk factors
Other diagnostic factors
- breathlessness/dyspnoea
- symptomatic hypotension
- chest pain/tightness/discomfort
- fatigue
- anxiety
- cognitive impairment
- dizziness
- polyuria
- abnormal breath sounds
- additional heart sounds
- elevated jugular venous pressure
- evidence of stroke
- pre-syncope and syncope
Risk factors
- increasing age
- hypertension
- heart failure
- diabetes mellitus
- obstructive sleep apnoea
- obesity
- coronary artery disease
- valve disease
- other cardiac disease
- regular, heavy alcohol consumption
- cardiac or thoracic surgery
- other atrial arrhythmias
- previous stroke/transient ischaemic attack
- hyperthyroidism
- athletic levels of physical activity
- COPD
- smoking
Diagnostic investigations
1st investigations to order
- ECG
- FBC
- clotting profile
- electrolytes, urea, and creatinine
- thyroid function
- CXR
- transthoracic echocardiography (TTE)
Investigations to consider
- cardiac troponin
- ABG
- CRP
- B-natriuretic peptide (BNP)/N-terminal prohormone B-natriuretic peptide (NT-pro-BNP)
- LFTs
- erythrocyte sedimentation rate
- transoesophageal echocardiogram (TOE)
- inpatient telemetry or 24-hour holter monitor
- coronary angiography (CT or conventional) or stress testing
- late gadolinium contrast-enhanced cardiac MR (CMR)
- brain CT
- brain MRI
- computed tomographic pulmonary angiography (CTPA)
Treatment algorithm
haemodynamically unstable
haemodynamically stable: onset <48 hours
haemodynamically stable: onset ≥48 hours or uncertain
post-stabilisation
Contributors
Expert advisers
Shrilla Banerjee, MD, FRCP
Consultant Interventional Cardiologist
East Surrey Hospital
Surrey and Sussex Healthcare NHS Trust
UK
Disclosures
SB has received speaker fees for educational lectures (presentation content was her own) and meeting participation from Menarini, Edwards Lifesciences, Abbott Vascular, and Shockwave IVL. She has also participated in an Advisory Board for Sahajanand Medical Technologies Limited. SB has received travel sponsorship from Biosensors International to attend the PCR meeting in Paris in 2022. She has prepared a manuscript on coronary microvascular dysfunction for Abbott for Cardiovascular News (no royalties).
Acknowledgements
BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work is retained in parts of the content:
Arti N. Shah, MS, MD
Director
Cardiac Electrophysiology
Elmhurst Hospital Center
Elmhurst
Assistant Professor of Medicine
Mount Sinai School of Medicine
New York
NY
ANS is an author of a number of references cited in this topic.
Bharat K. Kantharia MD, FRCP, FAHA, FACC, FESC, FHRS
Cardiovascular and Heart Rhythm Consultant
Attending and Consultant Cardiac Electrophysiologist
Mount Sinai Hospitals
New York Methodist Hospital
New York
NY
West Houston Medical Center
Memorial Hermann Hospital
Houston
TX
BKK is an author of a number of references cited in this topic.
Resham Baruah MBBS, BSc, MRCP, PhD
Consultant Cardiologist
Chelsea and Westminster Hospital and the Royal Brompton and Harefield NHS Trust
London
UK
RB has received honorarium/speaker fees from Novartis and Boehringer Ingleheim.
Adam D. Hartley MBBS, BSc, MRCP
Wellcome Trust Clinical Research Fellow
Imperial College London
Specialist Registrar in Cardiology
Imperial College Healthcare NHS Trust
London
UK
ADH declares that he has no competing interests.
Peer reviewers
Gregory Lip, MD, FRCP, DFM, FACC, FESC, FEHRA
Price-Evans Professor of Cardiovascular Medicine
University of Liverpool
Senior Investigator
National Institute for Health Research
UK
Distinguished Professor
Faculty of Medicine
Aalborg University
Denmark
Adjunct Professor
Yonsei University
Seoul
South Korea
Disclosures
GL is a consultant for Bayer/Janssen, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Novartis, Verseon, and Daiichi-Sankyo. He is a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, and Daiichi-Sankyo. No fees are directly received personally. GL is an author of a number of references cited in this topic.
Editors
Tannaz Aliabadi-Oglesby
Lead Section Editor, BMJ Best Practice
Disclosures
TAO declares that she has no competing interests.
Rachel Wheeler
Lead Section Editor, BMJ Best Practice
Disclosures
RW declares that she has no competing interests.
Jo Haynes
Head of Editorial, BMJ Knowledge Centre
Disclosures
JH declares that she has no competing interests.
Julie Costello
Comorbidities Editor, BMJ Best Practice
Disclosures
JC declares that she has no competing interests.
Adam Mitchell
Drug Editor, BMJ Best Practice
Disclosures
AM declares that he has no competing interests.
Shouvik Haldar
Consultant Cardiologist and Electrophysiologist
Royal Brompton and Harefield Hospitals
London
UK
Disclosures
SH was a Section Editor, BMJ Best Practice. SH declares that he has no competing interests.
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