Sections

Presentation

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.^[49]Symptomatic patients may benefit from intravenous (IV) rate-controlling agents, either calcium-channel blockers or beta-adrenergic blockers.

Although up to 90% of AF episodes may not cause symptoms,^[50]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, long-standing 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

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.

Differential Diagnoses

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Media Gallery

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 (AF).
Patient management for newly diagnosed atrial fibrillation (Afib). *Therapeutic anticoagulation implies either treatment with warfarin with a therapeutic international normalized ratio (INR) (2-3) or with newer oral anticoagulants (dabigatran, rivaroxaban, apixaban, or edoxaban). Transesophageal echocardiography (TEE)/cardioversion should be performed with an anticoagulation strategy using either low molecular-weight heparin (LMWH) 1 mg/kg twice daily as a bridge, with initiation of warfarin (INR 2-3) or newer oral anticoagulants.
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 right 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 right atrium and is used as the template during left atrial ablation procedures.

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Table 1. Stroke Rate in Patients with Nonvalvular Atrial Fibrillation not Treated with Anticoagulation ^[67]

CHA₂ DS₂-VASc Score	Unadjusted Stroke Rate (%/y)
0	0.2
1	0.6
2	2.2
3	3.2
4	4.8
5	7.2
6	9.7
7	11.2
8	10.8
9	12.2

Table 2. Recommendations for Antithrombotic Therapy in Patients with Nonvalvular Atrial Fibrillation

CHA₂ DS₂-VASc Score	Recommended Therapy
0	No therapy
1	No therapy, or aspirin 81-325 mg daily, or anticoagulation therapy (eg, warfarin [international normalized ratio (INR) goal 2-3], dabigatran, rivaroxaban, apixaban, edoxaban)
≥2	Anticoagulation therapy (eg, warfarin [INR goal 2-3], dabigatran, rivaroxaban, apixaban, edoxaban)

Table. Antithrombotic Therapy Recommendations for Atrial Fibrillation

Issuing Organization	Year	Patient Groups	Antithrombotic Therapy
American Heart Association/American College of Cardiology/ Heart Rhythm Society (AHA/ACC/HRS)^[1]	2014	AF with mechanical heart valve With prior stroke, TIA or CHA ₂DS ₂-VASc score ≥2 NVAF and CHA ₂DS ₂-VASc score ≥2 NVAF with CHA ₂DS ₂-VASc score ≥2 and end-stage CKD or on hemodialysis NVAF with CHA ₂DS ₂-VASc score ≥2 and moderate to severe CKD All patients	Warfarin therapy; target INR, 2.0-3.0 or 2.5-3.5 based on type and location of prosthesis Bridging therapy with unfractionated heparin or LMWH for patients undergoing procedures that require interruption of warfarin. Decisions on bridging therapy should balance the risks of stroke and bleeding. Oral anticoagulants: Warfarin (INR 2.0-3.0), dabigatran, apixaban, or rivaroxaban Warfarin (INR 2.0-3.0); if unable to maintain a therapeutic INR level with warfarin, use of a direct thrombin or factor Xa inhibitor (dabigatran, rivaroxaban, or apixaban) Warfarin (INR 2.0-3.0); direct thrombin or factor Xa inhibitors are not recommended Reduced doses of direct thrombin or factor Xa inhibitors may be considered (eg, dabigatran, rivaroxaban, apixaban), but safety and efficacy have not been established In patients receiving warfarin, the INR should be determined at least weekly during initiation of antithrombotic therapy and at least monthly when anticoagulation (INR in range) is stable Periodic reevaluation of the need and choice of anti-thrombotic therapy to reassess stroke and bleeding risks
American Heart Association/American Stroke Association (AHA/ASA)^[151]	2014	Valvular AF/ CHA ₂DS ₂-VASc score ≥2 NVAF// CHA ₂DS ₂-VASc score ≥2 and low risk for hemorrhagic complications NVAF, CHA ₂DS ₂-VASc score = 1, and low risk for hemorrhagic complications	Warfarin therapy; target INR, 2.0-3.0 Oral anticoagulant (warfarin, dabigatran, apixaban, or rivaroxaban) individualized based on patient risk factors (particularly risk for intracranial hemorrhage), cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics. No antithrombotic therapy, anticoagulant therapy, or aspirin therapy may be considered
American Academy of Neurology (AAN)^[97]	2014	NVAF and history of TIA or stroke; age >75 years, if no history of unprovoked bleeding or intracranial hemorrhage; patients with dementia or occasional falls; however in patients with moderate to severe dementia or frequent falls, risk-benefit ratio is uncertain Patients at moderate stroke risk in developing countries where newer anticoagulants are unavailable	Warfarin, target INR 2.0 to 3.0 Dabigatran, rivaroxaban, or apixaban (preferred) if at high risk for intracranial bleeding or unable to submit to frequent periodic INR testing Apixaban, if at increased risk for gastrointestinal bleeding Triflusal 600 mg/day plus moderate-intensity anticoagulation (INR 1.25–2.0) with acenocoumarol is likely more effective than acenocoumarol alone at the higher INR (2.0-3.0)
American College of Chest Physicians (ACCP)^[150]	2012	NVAF intermediate risk (CHADS₂ score = 1) or high risk (CHADS₂score ≥2)	Oral anticoagulants: dabigatran 150 mg BID preferred over warfarin (target INR range, 2.0-3.0) Patients who are unsuitable for or choose not to take an oral anticoagulant (for reasons other than concerns about major bleeding): combination therapy with aspirin and clopidogrel
European Society of Cardiology (ESC)^[149]	2012	CHA ₂DS ₂-VASc score = 0, and females aged < 65 years with CHA ₂DS ₂-VASc score = 1 CHA ₂DS ₂-VASc score = 1 CHA ₂DS ₂-VASc score ≥2 All patients Patients who refuse oral anticoagulants	No antithrombotic therapy Oral anticoagulants: Warfarin (INR 2.0-3.0) or dabigatran or rivaroxaban or apixaban based on assessment of risk of bleeding Oral anticoagulants: Dabigatran or rivaroxaban or apixaban preferred over warfarin (INR 2.0-3.0) When dabigatran is considered, 150 mg BID preferred; 110 mg BID is preferred for ages ≥80 years, concomitant use of interacting drugs, high bleeding risk or moderate renal impairment When rivaroxaban is considered, 20 mg OD preferred; 15 mg OD is preferred for those with high bleeding risk or moderate renal impairment Baseline and subsequent annual assessment of renal function (by CrCl) is recommended in patients following initiation of any novel oral anticoagulant (dabigatran, rivaroxaban, and apixaban), and 2-3 times per year in those with moderate renal impairment; novel oral anticoagulants are not recommended in patients with severe renal impairment (CrCl < 30 mL/min) Antiplatelet therapy should be considered, using combination therapy with aspirin 75–100 mg plus clopidogrel 75 mg daily (where there is a low risk of bleeding) or—less effectively—aspirin 75–325 mg daily
Note: Edoxaban was approved by the FDA in January 2015 for use as an oral anticoagulant in atrial fibrillation. AF = atrial fibrillation; BID = twice daily; CKD = chronic kidney disease; CrCl = creatinine clearance; INR = international normalized ratio; LMWH = low-molecular-weight heparin; NVAF = nonvalvular atrial fibrillation; OD = before bedtime; TIA = transient ischemic attack.

Table. Medications, Strategies, and Techniques Specified or Not Mentioned in the 2019 Guidelines

Type of Tachycardia	Treatment (Grade)	Not Mentioned in 2019 Guidelines
Narrow QRS tachycardias	Verapamil and diltiazem; beta-blockers (now all are grade IIa)	Amiodarone, digoxin
Wide QRS tachycardias	Procainamide, adenosine (both grade IIa); amiodarone (IIb)	Sotalol, lidocaine
Inappropriate sinus tachycardia	Beta-blockers (IIa)	Verapamil/diltiazem, catheter ablation
Postural orthostatic tachycardia syndrome	Salt and fluid intake (IIb)	Head-up tilt sleep, compression stockings, selective beta-blockers, fludrocortisone, clonidine, methylphenidate, fluoxetine, erythropoietin, ergotaminel octreotide, phenobarbitone
Focal atrial tachycardia	Acute: beta-blockers (IIa); flecainide/propafenone, amiodarone (IIb)	Acute: procainamide, sotalol, digoxin
Focal atrial tachycardia	Chronic: beta-blockers; verapamil and diltiazem (all IIa)	Chronic: amiodarone, sotalol, disopyramide
Atrial flutter	Acute: ibutilide (I); verapamil and diltiazem, beta-blockers (all IIa); atrial or transesophageal pacing (IIb); flecainide/propafenone (III)	Acute: digitalis
Atrial flutter	Chronic: —	Chronic: dofetilide, sotalol, flecainide, propafenone, procainamide, quinidine, disopyramide
Atrioventricular nodal re-entrant tachycardia (AVNRT)	Acute: —	Acute: amiodarone, sotalol, flecainide, propafenone
Atrioventricular nodal re-entrant tachycardia (AVNRT)	Chronic: verapamil and diltiazem; beta-blockers (all IIa)	Chronic: amiodarone, sotalol, flecainide, propafenone, “pill-in-the-pocket” approach
Atrioventricular re-entrant tachycardia (AVRT)	Beta-blockers (IIa); flecainide/propafenone (IIb)	Amiodarone, sotalol, “pill-in-the-pocket” approach
SVT in pregnancy	Verapamil (IIa); catheter ablation (IIa when fluoroless ablation is available)	Sotalol, propafenone, quinidine, procainamide
Adapted from Brugada J, Katritsis DG, Arbelo E, et al, for the ESC Scientific Document Group. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia. The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2019 Aug 31;ehz467. https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehz467/5556821

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Author

Lawrence Rosenthal, MD, PhD, FACC, FHRS 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, Heart Rhythm Society, Massachusetts Medical Society

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.

Mayank Sardana, MBBS Fellow in Cardiovascular Medicine, 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.

Additional Contributors

Mariclaire Cloutier Freelance editor, Medscape Drugs & Diseases

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