Atrial Fibrillation Clinical Presentation

  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD   more...
 
Updated: May 15, 2012
 

History

Clinical presentation spans the entire spectrum from asymptomatic atrial fibrillation (AF) with rapid ventricular response to cardiogenic shock or devastating cerebrovascular accident (CVA).

Initial evaluation of the patient with new-onset atrial fibrillation should focus on the patient's hemodynamic stability. Care of hemodynamically unstable patients is guided by Advanced Cardiac Life Support (ACLS) protocols, including immediate direct current (DC) cardioversion.[22] Symptomatic patients may benefit from intravenous (IV) rate-controlling agents, either calcium-channel blockers or beta-adrenergic blockers.

While up to 90% of AF episodes may not cause symptoms,[23] many patients experience a wide variety of symptoms, including palpitations, dyspnea, fatigue, dizziness, angina, and decompensated heart failure. In addition, AF can be associated with hemodynamic dysfunction, tachycardia-induced cardiomyopathy, and systemic thromboembolism.

Unstable patients requiring immediate DC cardioversion include the following:

  • Patients with decompensated congestive heart failure (CHF)
  • Patients with hypotension
  • Patients with uncontrolled angina/ischemia

Less severe symptoms and patient complaints include the following:

  • Palpitations
  • Fatigue or poor exercise tolerance
  • Presyncope or syncope
  • Generalized weakness, dizziness, fatigue

In addition to eliciting the symptoms above, history taking of any patient presenting with suspected AF should include questions relevant to temporality, precipitating factors (including hydration status, recent infections, alcohol use), history of pharmacologic or electric interventions and responses, and presence of heart disease. An effort should also be made to evaluate for potential comorbid diseases that contribute to initiation or maintenance of AF. Occasionally, a patient may have a clear and strong belief about the onset of symptoms that may be helpful in determining a course of action.

Initial history includes the following:

Documentation of clinical type of AF (paroxysmal, persistent, or permanent) (See Diagnostic Considerations.)

  • Assessment of type, duration, and frequency of symptoms
  • Assessment of precipitating factors (eg, exertion, sleep, caffeine, alcohol use)
  • Assessment of modes of termination (eg, vagal maneuvers)
  • Documentation of prior use of antiarrhythmics and rate-controlling agents
  • Assessment of presence of underlying heart disease

Documentation of any previous surgical or percutaneous AF ablation procedures

Next

Physical Examination

Physical examination always begins with airway, breathing, and circulation (ABCs) and vital signs, as these guide the pace of the intervention. The physical examination also provides information on underlying causes and sequelae of atrial fibrillation.

Vital signs

Heart rate, blood pressure, respiratory rate, and oxygen saturation are particularly important in evaluating hemodynamic stability and adequacy of rate control in AF.

Patients will have an irregularly irregular pulse and will commonly be tachycardic, with heart rates typically in the 110- to 140-range, but rarely over 160-170. Patients who are hypothermic or who have cardiac drug toxicity may present with bradycardic atrial fibrillation.

Head and neck

Examination of the head and neck may reveal exophthalmos, thyromegaly, elevated jugular venous pressures, or cyanosis. Carotid artery bruits suggest peripheral arterial disease and increase the likelihood of comorbid coronary artery disease.

Pulmonary

The pulmonary examination may reveal evidence of heart failure (eg, rales, pleural effusion). Wheezes or diminished breath sounds are suggestive of underlying pulmonary disease (eg, chronic obstructive pulmonary disease [COPD], asthma).

Cardiac

The cardiac examination is central to the physical examination of the patient with AF. Thorough palpation and auscultation are necessary to evaluate for valvular heart disease or cardiomyopathy. A displaced point of maximal impulse or S3 suggests ventricular enlargement and elevated left ventricular pressure. A prominent P2 points to the presence of pulmonary hypertension.

Abdomen

The presence of ascites, hepatomegaly, or hepatic capsular tenderness suggests right ventricular failure or intrinsic liver disease. Left upper quadrant pain may suggest splenic infarct from peripheral embolization.

Lower extremities

Examination of the lower extremities may reveal cyanosis, clubbing, or edema. A cool or cold pulseless extremity may suggest peripheral embolization, and assessment of peripheral pulses may lead to the diagnosis of peripheral arterial disease or diminished cardiac output.

Neurologic

Signs of a transient ischemic attack or cerebrovascular accident may be discovered. Evidence of prior stroke and increased reflexes is suggestive of hyperthyroidism.

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Contributor Information and Disclosures
Author

Lawrence Rosenthal, MD, PhD, FACC, FHRS  Associate Professor of Medicine, Director, Section of Cardiac Pacing and Electrophysiology, Director of EP Fellowship Program, Division of Cardiovascular Disease, University of Massachusetts Memorial Medical Center

Lawrence Rosenthal, MD, PhD, FACC, FHRS is a member of the following medical societies: American College of Cardiology, American Heart Association, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Pierre Borczuk, MD  Assistant Professor of Medicine, Harvard Medical School; Associate in Emergency Medicine, Massachusetts General Hospital

Pierre Borczuk, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Arvind Chandrakantan, MD, FAAP  Clinical Assistant Professor of Anesthesiology and Pediatrics, Stony Brook University Medical Center

Disclosure: Nothing to disclose.

Mark Lloyd Greenberg, MD  Director, Clinical Electrophysiology and Pacing, Director, Clinical Cardiac Electrophysiology Training Program, Dartmouth-Hitchcock Medical Center; Associate Professor of Medicine, Dartmouth Medical School

Mark Lloyd Greenberg, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, and American Medical Association

Disclosure: Nothing to disclose.

Abraham G Kocheril, MD, FACC, FACP, FHRS  Professor of Medicine, University of Illinois College of Medicine

Abraham G Kocheril, MD, FACC, FACP, FHRS is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, Cardiac Electrophysiology Society, Central Society for Clinical Research, Heart Failure Society of America, and Illinois State Medical Society

Disclosure: Nothing to disclose.

William Lober, MD, MS  Associate Professor, Health Informatics and Global Health, Schools of Medicine, Nursing, and Public Health, University of Washington

Disclosure: Nothing to disclose.

David D McManus  MD, Assistant Professor of Medicine, University of Massachusetts Medical Center; Director, Atrial Fibrillation Research, University of Massachusetts Memorial Medical Center

Disclosure: Nothing to disclose.

Gary Setnik, MD  Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

Ali A Sovari, MD, FACP  Clinical and Research Fellow in Cardiovascular Medicine, Section of Cardiology, University of Illinois College of Medicine; Staff Physician and Hospitalist, St John Regional Medical Center, Cogent Healthcare, Inc

Ali A Sovari, MD, FACP is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Physiological Society, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Justin D Pearlman, MD, ME, PhD, FACC, MA  Chief, Division of Cardiology, Director of Cardiology Consultative Service, Director of Cardiology Clinic Service, Director of Cardiology Non-Invasive Laboratory, Director of Cardiology Quality Program KMC, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School

Justin D Pearlman, MD, ME, PhD, FACC, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Brian Olshansky, MD  Professor of Medicine, Department of Internal Medicine, University of Iowa College of Medicine

Brian Olshansky, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, Cardiac Electrophysiology Society, and Heart Rhythm Society

Disclosure: Guidant/Boston Scientific Honoraria Speaking and teaching; Medtronic Honoraria Speaking and teaching; Guidant/Boston Scientific Consulting fee Consulting

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD  Professor of Medicine and Pharmacology, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)

Disclosure: Nothing to disclose.

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Ventricular rate varies from 130-168 beats per minute. Rhythm is irregularly irregular. P waves are not discernible.
Classification scheme for patients with atrial fibrillation.
Patient management for newly diagnosed atrial fibrillation. Subtherapeutic INR: INR < 2 for 3 consecutive weeks. Warfarin: INR target 2-3. TEE/cardioversion: low molecular weight heparin 1 mg/kg bid as a bridge with initiation of warfarin INR 2-3.
Antiarrhythmic drug algorithm for the medical management of sinus rhythm in patients with atrial fibrillation.
The image on the right is a reconstructed 3-dimensional image of the left atrium in a patient undergoing atrial fibrillation ablation. The figure on the left was created with a mapping catheter using Endocardial Solutions mapping technology. It represents the endocardial shell of the left atrium and is used as the template during left atrial ablation procedures.
Table 1. Risk Factors for Stroke in Patients with Nonvalvular Atrial Fibrillation
Risk FactorsRelative Risk
Prior stroke or TIA2.5
History of hypertension1.6
Heart failure and/or reduced left ventricular function1.4
Advanced age1.4
Diabetes1.7
Coronary artery disease1.5
Table 2. Adjusted Stroke Rate in Patients with Nonvalvular Atrial Fibrillation not Treated with Anticoagulation
CHADS2 ScoreAdjusted Stroke Rate (%/y)
01.9
12.8
24.0
35.9
48.5
512.5
618.2
Table 3. Recommendations for Antithrombotic Therapy in Patients with Nonvalvular Atrial Fibrillation
Risk CategoryRecommended Therapy
No risk factorsAspirin 81-325 mg daily
One moderate-risk factorAspirin 81-325 mg daily or warfarin (INR 2-3)
Any high-risk factor or more than 1 moderate-risk factorWarfarin (INR 2-3)
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