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Introduction to Atrial Fibrillation
This section covers the clinical presentation, classification and origin of AF, and its management
In this section:
Clinical presentation of AF
- In AF the atria beat irregularly and often rapidly, as a result, the ventricles cannot adequately fill with blood, cardiac output is reduced and a thrombus can form from stagnant blood in the fibrillating left atrium
- AF can present with a variety of symptoms (listed below), which can be mild to severe in severity, but some patients have no symptoms at all:
- Fatigue
- Palpitations
- Syncope/dizziness
- Angina/chest pains
- Dyspnoea/breathlessness
- Stroke/transient ischaemic attack
- AF has a heterogeneous clinical presentation, occurring in the presence or absence of detectable heart disease or related symptoms; therefore, clinical guidelines feature recommendations for appropriate classification/definition
| Classification | Clinical presentation |
|---|---|
| First diagnosed AF |
|
| Paroxysmal |
|
| Persistent |
|
| Long-standing persistent |
|
| Permanent |
|
Origin of AF: NVAF or VAF?
- Definitions of NVAF and VAF remain a matter of debate; current definitions are summarized in the table below
- Classification of AF as VAF or NVAF facilitates identification of risk for thromboembolic events and the need for a specific antithrombotic strategy3
| Origin of AF | Definition according to guidelines |
|---|---|
| NVAF | AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair1 |
| VAF | AF related to rheumatic valvular disease (predominantly mitral stenosis) or mechanical heart valves2 |
Investigation
Diagnosing atrial fibrillation from ECGs
Atrial fibrillation (AF) is most commonly diagnosed on the basis of an irregular electrocardiogram (ECG). Here, we review some of the key hallmarks of AF using example patient ECGs (provided by Dr Joe Martins and Dr Ron Pisters)
Approval Number: PP-XAR-ALL-0224-1
Because AF is frequently intermittent and can be asymptomatic or associated with non-specific symptoms, detection and diagnosis can be difficult.
Investigations for the clinical evaluation of AF include4
- ECG: Upon detection of an irregular pulse, an ECG should be performed in all cases of suspected AF, whether symptomatic or not
- With suspected paroxysmal AF, a 24-hour ambulatory ECG monitor should be used if asymptomatic episodes are suspected or if episodes are <24 hours apart
- An event recorder ECG should be used where symptomatic episodes are >24 hours apart
- Echocardiograms: to assess the dimensions of the left atrium and left ventricle and left ventricular wall thickness and function, and to exclude occult valvular or pericardial disease and hypertrophic cardiomyopathy
- TTE: performed in patients with AF when:
- A baseline echocardiogram is important for long-term management
- A rhythm-control strategy that includes cardioversion (electrical or pharmacological) is being considered
- There is a high risk or a suspicion of underlying structural/functional heart disease that influences subsequent management
- Refinement of clinical risk stratification for antithrombotic therapy is needed
- TEE: performed in patients with AF when:
- TTE demonstrates an abnormality (such as valvular heart disease) that warrants further specific assessment
- TEE-guided cardioversion is being considered
- TTE: performed in patients with AF when:
- Blood tests are important for first episodes of AF and when the ventricular rate is difficult to control – these include tests of thyroid, renal and hepatic function
Management approaches
- Subsequent sections consider how management approaches differ according to the type of AF and specific patient characteristics.
- In general, management of patients with AF involves three main objectives, which are not mutually exclusive:1,2
- Rate control
- Prevention of thromboembolism
- Correction of rhythm disturbance
- To find out more about the potentially serious consequences of AF and the critical nature of its management, click on the link to next section below
- In general, management of patients with AF involves three main objectives, which are not mutually exclusive:1,2
References
- Hindricks G, Potpara T, Dagres N et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J 2020: doi:10.1093/eurheartj/ehaa612. Return to content
- January CT, Wann LS, Alpert JS et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014;64:e1–76. Return to content
- Fauchier L, Philippart R, Clementy N et al. How to define valvular atrial fibrillation? Arch Cardiovasc Dis 2015;108:530–539. Return to content
- January CT, Wann LS, Calkins H et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in collaboration with the Society of Thoracic Surgeons. Circulation 2019;140:e125–e151. Return to content
- National Institute for Health and Care Excellence. Atrial fibrillation: management. Clinical guideline [CG180]. 2014. Available at: https://www.nice.org.uk/guidance/cg180 [accessed 20 November 2020]. National Institute for Health and Care Excellence. Atrial fibrillation: management. Clinical guideline [CG180]. 2014. Available at: https://www.nice.org.uk/guidance/cg180 [accessed 20 November 2020]. Return to content
See Also
Peripheral Artery Disease: causes and consequences
See Also
Coronary Artery Disease: causes and consequences
