New-onset atrial fibrillation

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Last reviewed: 14 Jan 2025
Last updated: 22 Apr 2024

Summary

Definition

History and exam

Key diagnostic factors

  • palpitations
  • irregular pulse rate
  • risk factors
Full details

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
Full details

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
Full details

Diagnostic investigations

1st investigations to order

  • ECG
  • FBC
  • clotting profile
  • electrolytes, urea, and creatinine
  • thyroid function
  • CXR
  • transthoracic echocardiography (TTE)
Full details

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)
Full details

Treatment algorithm

ACUTE

haemodynamically unstable

haemodynamically stable: onset <48 hours

haemodynamically stable: onset ≥48 hours or uncertain

ONGOING

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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