Chronic atrial fibrillation (AF) is a longstanding chaotic and irregular atrial arrhythmia. It is primarily defined based on duration and frequency of episodes; therefore, chronic AF could be paroxysmal, persistent, or permanent.
Prevalence increases progressively with age.
Patients frequently have coexisting cardiac or noncardiac conditions, such as hypertension, coronary artery disease, valvular disease, heart failure, obesity, and sleep apnea or pulmonary disease.
Causes significant morbidity (e.g., palpitations, dyspnea, 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 utilizing 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 optimize patient outcome.
AF is a supraventricular tachyarrhythmia. It is characterized 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. It is primarily defined based on duration and frequency of episodes; therefore, chronic AF could be paroxysmal, persistent, or permanent, and even new onset if detected for the first time.
For details on new-onset AF, please see New-onset atrial fibrillation.
History and exam
Key diagnostic factors
- presence of valvular heart disease, coronary artery disease, hypertension, pericarditis, cardiomyopathy, and other arrhythmias
- presence of diabetes mellitus, thyroid disease, alcohol abuse, and cancer
- 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
- valvular disease
- hypertrophic cardiomyopathy
- alcohol abuse
- male sex
- presence of other arrhythmias
- thyroid disease
- autonomic neuronal dysfunction
- sleep-disordered breathing
- caffeine abuse
- working long hours
- excessive exercise
- chronic obstructive pulmonary disease
- chronic kidney disease
1st investigations to order
- thyroid profile
- serum electrolytes (including serum magnesium) and BUN
Investigations to consider
- serum aminotransferases
- prolonged ECG monitoring
paroxysmal or persistent AF: hemodynamically unstable
paroxysmal or persistent AF: hemodynamically stable
- Atrial flutter with variable atrioventricular (AV) conduction
- Multifocal atrial tachycardia
- Atrial tachycardia with variable AV conduction
- 2020 update to the 2016 ACC/AHA clinical performance and quality measures for adults with atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures
- Atrial fibrillation: diagnosis and management
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