Table 30

Clinical Evaluation in Patients With AF

Minimum evaluation
  • 1. History and physical examination, to define

  • Presence and nature of symptoms associated with AF

  • Clinical type of AF (paroxysmal, persistent, or permanent)

  • Onset of first symptomatic attack or date of discovery of AF

  • Frequency, duration, precipitating factors, and modes of termination of AF

  • Response to any pharmacological agents that have been administered

  • Presence of any underlying heart disease or other reversible conditions (e.g., hyperthyroidism or alcohol consumption)

  • 2. ECG, to identify

  • Rhythm (verify AF)

  • LV hypertrophy

  • P-wave duration and morphology or fibrillatory waves

  • Preexcitation

  • Bundle-branch block

  • Prior MI

  • Other atrial arrhythmias

  • To measure and follow the R-R, QRS, and QT intervals in conjunction with antiarrhythmic drug therapy

  • 3. Transthoracic echocardiogram, to identify

  • Valvular heart disease

  • LA and RA size

  • LV and RV size and function

  • Peak RV pressure (pulmonary hypertension)

  • LV hypertrophy

  • LA thrombus (low sensitivity)

  • Pericardial disease

  • 4. Blood tests of thyroid, renal, and hepatic function

  • For a first episode of AF, when the ventricular rate is difficult to control

Additional testing (one or several tests may be necessary)
  • 1. 6-Minute walk test

  • If the adequacy of rate control is in question

  • 2. Exercise testing

  • If the adequacy of rate control is in question (permanent AF)

  • To reproduce exercise-induced AF

  • To exclude ischemia before treatment of selected patients with a type IC antiarrhythmic drug

  • 3. Holter monitoring or event recording

  • If diagnosis of the type of arrhythmia is in question

  • As a means of evaluating rate control

  • 4. Transesophageal echocardiography

  • To identify LA thrombus (in the LA appendage)

  • To guide cardioversion

  • 5. Electrophysiological study

  • To clarify the mechanism of wide-QRS-complex tachycardia

  • To identify a predisposing arrhythmia such as atrial flutter or paroxysmal supraventricular tachycardia

  • To seek sites for curative ablation or AV conduction block/modification

  • 6. Chest x-ray to evaluate

  • Lung parenchyma, when clinical findings suggest an abnormality

  • Pulmonary vasculature, when clinical findings suggest an abnormality

Reproduced from Fuster et al. (6).

Type IC refers to the Vaughan Williams classification of antiarrhythmic drugs.

AF indicates atrial fibrillation; AV, atrioventricular; ECG, electrocardiogram; LA, left atrial; LV, left ventricular; MI, myocardial infarction; RA, right atrial; and RV, right ventricular.