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Atrial Fibrillation Differential Diagnoses

  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
 
Updated: Jan 02, 2016
 
 

Diagnostic Considerations

The diagnosis of atrial fibrillation is based on the physical finding of an irregular heart rhythm and is confirmed with an ECG or rhythm strip.

When atrial fibrillation is suspected during auscultation of the heart with irregularly irregular beats, obtaining a 12-lead electrocardiography is the next step. Because atrial fibrillation is due to irregular atrial activation at the rate of 350-600 bpm with irregular conduction through the atrioventricular node, it appears on ECG as irregularly irregular narrow complex tachycardia. The F waves may be seen as fibrillatory waves or may be absent. Unless the heart is under excess sympathetic or parasympathetic stimulation, the ventricular rate is usually between 80 and 180 bpm.

With an abnormality in the intraventricular conduction system, the QRS complexes may become wide. It is important to pay attention to the electrocardiographic signs of associated cardiac diseases, such as left ventricular hypertrophy and preexcitation.

Differential Diagnoses

 
 
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, Massachusetts Medical Society, American Heart Association

Disclosure: Nothing to disclose.

Coauthor(s)

David D McManus, MD, MSc, FACC, FHRS Director, Atrial Fibrillation Program, Assistant Professor of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD Professor of Medicine, Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine; Cardiologist/Electrophysiologist, University of Maryland Medical System and VA Maryland Health Care System

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association, Heart Rhythm Society

Disclosure: Nothing to disclose.

Acknowledgements

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.

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.

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.

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

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.

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

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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 Factors Relative Risk
Prior stroke or TIA 2.5
History of hypertension 1.6
Heart failure and/or reduced left ventricular function 1.4
Advanced age 1.4
Diabetes 1.7
Coronary artery disease 1.5
Table 2. Adjusted Stroke Rate in Patients with Nonvalvular Atrial Fibrillation not Treated with Anticoagulation
CHADS2 Score Adjusted Stroke Rate (%/y)
0 1.9
1 2.8
2 4.0
3 5.9
4 8.5
5 12.5
6 18.2
Table 3. Recommendations for Antithrombotic Therapy in Patients with Nonvalvular Atrial Fibrillation
Risk Category Recommended Therapy
No risk factors Aspirin 81-325 mg daily
One moderate-risk factor Aspirin 81-325 mg daily or warfarin (INR 2-3)
Any high-risk factor or more than 1 moderate-risk factor Warfarin (INR 2-3)
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