Atrial Fibrillation Clinical Presentation

Updated: Nov 18, 2019
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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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.


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).


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.


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.


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