Atrial fibrillation differential diagnosis: Difference between revisions
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|Atrial Fibrillation<ref name="pmid24837984">{{cite journal |vauthors=Lankveld TA, Zeemering S, Crijns HJ, Schotten U |title=The ECG as a tool to determine atrial fibrillation complexity |journal=Heart |volume=100 |issue=14 |pages=1077–84 |date=July 2014 |pmid=24837984 |doi=10.1136/heartjnl-2013-305149 |url=}}</ref><ref name="pmid22518390">{{cite journal |vauthors=Harris K, Edwards D, Mant J |title=How can we best detect atrial fibrillation? |journal=J R Coll Physicians Edinb |volume=42 Suppl 18 |issue= |pages=5–22 |date=2012 |pmid=22518390 |doi=10.4997/JRCPE.2012.S02 |url=}}</ref> | |'''Atrial Fibrillation<ref name="pmid24837984">{{cite journal |vauthors=Lankveld TA, Zeemering S, Crijns HJ, Schotten U |title=The ECG as a tool to determine atrial fibrillation complexity |journal=Heart |volume=100 |issue=14 |pages=1077–84 |date=July 2014 |pmid=24837984 |doi=10.1136/heartjnl-2013-305149 |url=}}</ref><ref name="pmid22518390">{{cite journal |vauthors=Harris K, Edwards D, Mant J |title=How can we best detect atrial fibrillation? |journal=J R Coll Physicians Edinb |volume=42 Suppl 18 |issue= |pages=5–22 |date=2012 |pmid=22518390 |doi=10.4997/JRCPE.2012.S02 |url=}}</ref>''' | ||
|Irregularly irregular | | | ||
|On a 10-second 12-lead EKG strip, multiply number of QRS complexes by 6 | * Irregularly irregular | ||
|Absent, fibrillatory waves | | | ||
|Absent | * On a 10-second 12-lead EKG strip, multiply number of QRS complexes by 6 | ||
|Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction | | | ||
|Does not break with adenosine or vagal maneuvers | * Absent, fibrillatory waves | ||
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* Absent | |||
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* Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction | |||
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* Does not break with adenosine or vagal maneuvers | |||
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* 2.7–6.1 million people in the United States have AFib | * 2.7–6.1 million people in the United States have AFib | ||
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* Left chamber enlargement | * Left chamber enlargement | ||
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|Atrial Flutter | |'''Atrial Flutter''' | ||
|Regular or Irregular | | | ||
|75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) bpm, but 150 is more common | * Regular or Irregular | ||
|Sawtooth pattern of P waves at 250 to 350 beats per minute | | | ||
|Varies depending upon the magnitude of the block, but is short | * 75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) bpm, but 150 is more common | ||
|Less than 0.12 seconds, consistent, and normal in morphology | | | ||
|Conduction may vary in response to drugs and maneuvers dropping the rate from 150 to 100 or to 75 bpm | * Sawtooth pattern of P waves at 250 to 350 beats per minute | ||
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* Varies depending upon the magnitude of the block, but is short | |||
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* Less than 0.12 seconds, consistent, and normal in morphology | |||
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* Conduction may vary in response to drugs and maneuvers dropping the rate from 150 to 100 or to 75 bpm | |||
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* Incidence: 88 per 100,000 individuals | * Incidence: 88 per 100,000 individuals | ||
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*Alcohol | *Alcohol | ||
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|Atrioventricular nodal reentry tachycardia (AVNRT)<ref name="pmid27617092">{{cite journal |vauthors=Katritsis DG, Josephson ME |title=Classification, Electrophysiological Features and Therapy of Atrioventricular Nodal Reentrant Tachycardia |journal=Arrhythm Electrophysiol Rev |volume=5 |issue=2 |pages=130–5 |date=August 2016 |pmid=27617092 |pmc=5013176 |doi=10.15420/AER.2016.18.2 |url=}}</ref><ref name="pmid20458824">{{cite journal |vauthors=Letsas KP, Weber R, Siklody CH, Mihas CC, Stockinger J, Blum T, Kalusche D, Arentz T |title=Electrocardiographic differentiation of common type atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia via a concealed accessory pathway |journal=Acta Cardiol |volume=65 |issue=2 |pages=171–6 |date=April 2010 |pmid=20458824 |doi=10.2143/AC.65.2.2047050 |url=}}</ref> | |'''Atrioventricular nodal reentry tachycardia (AVNRT)<ref name="pmid27617092">{{cite journal |vauthors=Katritsis DG, Josephson ME |title=Classification, Electrophysiological Features and Therapy of Atrioventricular Nodal Reentrant Tachycardia |journal=Arrhythm Electrophysiol Rev |volume=5 |issue=2 |pages=130–5 |date=August 2016 |pmid=27617092 |pmc=5013176 |doi=10.15420/AER.2016.18.2 |url=}}</ref><ref name="pmid20458824">{{cite journal |vauthors=Letsas KP, Weber R, Siklody CH, Mihas CC, Stockinger J, Blum T, Kalusche D, Arentz T |title=Electrocardiographic differentiation of common type atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia via a concealed accessory pathway |journal=Acta Cardiol |volume=65 |issue=2 |pages=171–6 |date=April 2010 |pmid=20458824 |doi=10.2143/AC.65.2.2047050 |url=}}</ref>''' | ||
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* Inverted, superimposed on or buried within the QRS complex (pseudo R prime in V1/pseudo S wave in inferior leads) | |||
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* Absent (P wave can appear after the QRS complex and before the T wave, and in atypical AVNRT, the P wave can appear just before the QRS complex) | |||
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* Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction, QRS alternans may be present | |||
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* May break with adenosine or vagal maneuvers | |||
|May break with adenosine or vagal maneuvers | | | ||
|60%-70% of all SVTs | * 60%-70% of all SVTs | ||
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|Multifocal Atrial Tachycardia<ref name="pmid2570520">{{cite journal |vauthors=Scher DL, Arsura EL |title=Multifocal atrial tachycardia: mechanisms, clinical correlates, and treatment |journal=Am. Heart J. |volume=118 |issue=3 |pages=574–80 |date=September 1989 |pmid=2570520 |doi=10.1016/0002-8703(89)90275-5 |url=}}</ref><ref name="pmid11884328">{{cite journal |vauthors=Goodacre S, Irons R |title=ABC of clinical electrocardiography: Atrial arrhythmias |journal=BMJ |volume=324 |issue=7337 |pages=594–7 |date=March 2002 |pmid=11884328 |pmc=1122515 |doi=10.1136/bmj.324.7337.594 |url=}}</ref> | |'''Multifocal Atrial Tachycardia<ref name="pmid2570520">{{cite journal |vauthors=Scher DL, Arsura EL |title=Multifocal atrial tachycardia: mechanisms, clinical correlates, and treatment |journal=Am. Heart J. |volume=118 |issue=3 |pages=574–80 |date=September 1989 |pmid=2570520 |doi=10.1016/0002-8703(89)90275-5 |url=}}</ref><ref name="pmid11884328">{{cite journal |vauthors=Goodacre S, Irons R |title=ABC of clinical electrocardiography: Atrial arrhythmias |journal=BMJ |volume=324 |issue=7337 |pages=594–7 |date=March 2002 |pmid=11884328 |pmc=1122515 |doi=10.1136/bmj.324.7337.594 |url=}}</ref>''' | ||
|Irregular | | | ||
|Atrial rate is > 100 beats per minute | * Irregular | ||
|Varying morphology from at least three different foci | | | ||
|Variable PR intervals, RR intervals, and PP intervals | * Atrial rate is > 100 beats per minute | ||
|Less than 0.12 seconds, consistent, and normal in morphology | | | ||
|Does not terminate with adenosine or vagal maneuvers | * Varying morphology from at least three different foci | ||
* Absence of one dominant atrial pacemaker, can be mistaken for atrial fibrillation if the P waves are of low amplitude | |||
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* Variable PR intervals, RR intervals, and PP intervals | |||
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* Less than 0.12 seconds, consistent, and normal in morphology | |||
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* Does not terminate with adenosine or vagal maneuvers | |||
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|High incidence in the elderly and in those with COPD | * 0.05% to 0.32% of electrocardiograms in general hospital admissions | ||
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* High incidence in the elderly and in those with COPD | |||
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|Paroxysmal Supraventricular Tachycardia | |'''Paroxysmal Supraventricular Tachycardia''' | ||
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* Regular | * Regular | ||
|150 and 240 beats per minute | | | ||
* 150 and 240 beats per minute | |||
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* Absent | * Absent | ||
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* Wolff-Parkinson-White syndrome | * Wolff-Parkinson-White syndrome | ||
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|Wolff-Parkinson-White Syndrome<ref name="pmid24982705">{{cite journal |vauthors=Rao AL, Salerno JC, Asif IM, Drezner JA |title=Evaluation and management of wolff-Parkinson-white in athletes |journal=Sports Health |volume=6 |issue=4 |pages=326–32 |date=July 2014 |pmid=24982705 |pmc=4065555 |doi=10.1177/1941738113509059 |url=}}</ref><ref name="pmid10597097">{{cite journal |vauthors=Rosner MH, Brady WJ, Kefer MP, Martin ML |title=Electrocardiography in the patient with the Wolff-Parkinson-White syndrome: diagnostic and initial therapeutic issues |journal=Am J Emerg Med |volume=17 |issue=7 |pages=705–14 |date=November 1999 |pmid=10597097 |doi=10.1016/s0735-6757(99)90167-5 |url=}}</ref> | |'''Wolff-Parkinson-White Syndrome<ref name="pmid24982705">{{cite journal |vauthors=Rao AL, Salerno JC, Asif IM, Drezner JA |title=Evaluation and management of wolff-Parkinson-white in athletes |journal=Sports Health |volume=6 |issue=4 |pages=326–32 |date=July 2014 |pmid=24982705 |pmc=4065555 |doi=10.1177/1941738113509059 |url=}}</ref><ref name="pmid10597097">{{cite journal |vauthors=Rosner MH, Brady WJ, Kefer MP, Martin ML |title=Electrocardiography in the patient with the Wolff-Parkinson-White syndrome: diagnostic and initial therapeutic issues |journal=Am J Emerg Med |volume=17 |issue=7 |pages=705–14 |date=November 1999 |pmid=10597097 |doi=10.1016/s0735-6757(99)90167-5 |url=}}</ref>''' | ||
|Regular | | | ||
|Atrial rate is nearly 300 bpm and ventricular rate is at 150 bpm | * Regular | ||
|With orthodromic conduction due to a bypass tract, the P wave generally follows the QRS complex, whereas in AVNRT, the P wave is generally buried in the QRS complex. | | | ||
|Less than 0.12 seconds | * Atrial rate is nearly 300 bpm and ventricular rate is at 150 bpm | ||
|A delta wave and evidence of ventricular pre-excitation if there is conduction to the ventricle via ante-grade conduction down an accessory pathway | | | ||
|May break in response to procainamide, adenosine, vagal maneuvers | * With orthodromic conduction due to a bypass tract, the P wave generally follows the QRS complex, whereas in AVNRT, the P wave is generally buried in the QRS complex. | ||
|Worldwide prevalence of WPW syndrome is 100 - 300 per 100,000 | | | ||
* Less than 0.12 seconds | |||
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* A delta wave and evidence of ventricular pre-excitation if there is conduction to the ventricle via ante-grade conduction down an accessory pathway | |||
* A delta wave and pre-excitation may not be present because bypass tracts do not conduct ante-grade. | |||
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* May break in response to procainamide, adenosine, vagal maneuvers | |||
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* Worldwide prevalence of WPW syndrome is 100 - 300 per 100,000 | |||
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|Ventricular Fibrillation | |'''Ventricular Fibrillation''' | ||
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* Irregular | |||
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|Myocardial ischemia / infarction | * 150 to 500 bpm | ||
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* Absent | |||
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* Absent | |||
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* Absent (R on T phenomenon in the setting of ischemia) | |||
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* Myocardial ischemia / infarction | |||
* Cardiomyopathy | |||
* Channelopathies e.g. Long QT (acquired / congenital) | |||
* Aortic stenosis | |||
* Aortic dissection | |||
* Myocarditis | |||
* Cardiac tamponade | |||
* Blunt trauma (Commotio Cordis) | |||
* Sepsis | |||
* Hypothermia | |||
* Pneumothroax | |||
* Seizures | |||
* Stroke | |||
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|Ventricular Tacycardia | |'''Ventricular Tacycardia''' | ||
|Regular | | | ||
|> 100 beats per minute | * Regular | ||
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* > 100 beats per minute | |||
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* Wide complex, QRS duration > 120 milliseconds | |||
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Revision as of 14:51, 13 December 2019
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Atrial fibrillation differential diagnosis On the Web | |
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Risk calculators and risk factors for Atrial fibrillation differential diagnosis | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Atrial fibrillation must be distinguished from other common atrial arrhythmias, which include atrial flutter, atrial tachycardia, paroxysmal supraventricular tachycardia, Wolff-Parkinson-White syndrome, and atrioventricular nodal reentry tachycardia.
Differentiating Atrial Fibrillation from other Diseases
Atrial fibrillation has to be differnetiated from other diseases like:
- Atrial flutter
- Atrial tachycardia
- Atrioventricular nodal reentry tachycardia (AVNRT)
- Multifocal atrial tachycardia
- Paroxysmal supraventricular tachycardia
- Wolff-Parkinson-White syndrome
The differentiating features are largely based on both EKG findings and cardiovascular examination.
- Atrial fibrillation is irregularly irregular, while the other rhythms such as atrial flutter, sinus tachycardia, AV nodal reentry tachycardia and paroxysmal supraventricular tachycardia are all much more regular.
- An atrioventricular nodal reentry tachycardia will often break with either carotid sinus massage or AV nodal blocking agents.
- If the patient has Wolff-Parkinson-White syndrome there may be much more rapid conduction. The presence of the delta wave on EKG is characteristic.
Arrhythmia | Rhythm | Rate | P wave | PR Interval | QRS Complex | Response to Maneuvers | Epidemiology | Co-existing Conditions |
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Atrial Fibrillation[1][2] |
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Atrial Flutter |
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Atrioventricular nodal reentry tachycardia (AVNRT)[3][4] |
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Multifocal Atrial Tachycardia[5][6] |
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Paroxysmal Supraventricular Tachycardia |
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Wolff-Parkinson-White Syndrome[7][8] |
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Ventricular Fibrillation |
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Ventricular Tacycardia |
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References
- ↑ Lankveld TA, Zeemering S, Crijns HJ, Schotten U (July 2014). "The ECG as a tool to determine atrial fibrillation complexity". Heart. 100 (14): 1077–84. doi:10.1136/heartjnl-2013-305149. PMID 24837984.
- ↑ Harris K, Edwards D, Mant J (2012). "How can we best detect atrial fibrillation?". J R Coll Physicians Edinb. 42 Suppl 18: 5–22. doi:10.4997/JRCPE.2012.S02. PMID 22518390.
- ↑ Katritsis DG, Josephson ME (August 2016). "Classification, Electrophysiological Features and Therapy of Atrioventricular Nodal Reentrant Tachycardia". Arrhythm Electrophysiol Rev. 5 (2): 130–5. doi:10.15420/AER.2016.18.2. PMC 5013176. PMID 27617092.
- ↑ Letsas KP, Weber R, Siklody CH, Mihas CC, Stockinger J, Blum T, Kalusche D, Arentz T (April 2010). "Electrocardiographic differentiation of common type atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia via a concealed accessory pathway". Acta Cardiol. 65 (2): 171–6. doi:10.2143/AC.65.2.2047050. PMID 20458824.
- ↑ Scher DL, Arsura EL (September 1989). "Multifocal atrial tachycardia: mechanisms, clinical correlates, and treatment". Am. Heart J. 118 (3): 574–80. doi:10.1016/0002-8703(89)90275-5. PMID 2570520.
- ↑ Goodacre S, Irons R (March 2002). "ABC of clinical electrocardiography: Atrial arrhythmias". BMJ. 324 (7337): 594–7. doi:10.1136/bmj.324.7337.594. PMC 1122515. PMID 11884328.
- ↑ Rao AL, Salerno JC, Asif IM, Drezner JA (July 2014). "Evaluation and management of wolff-Parkinson-white in athletes". Sports Health. 6 (4): 326–32. doi:10.1177/1941738113509059. PMC 4065555. PMID 24982705.
- ↑ Rosner MH, Brady WJ, Kefer MP, Martin ML (November 1999). "Electrocardiography in the patient with the Wolff-Parkinson-White syndrome: diagnostic and initial therapeutic issues". Am J Emerg Med. 17 (7): 705–14. doi:10.1016/s0735-6757(99)90167-5. PMID 10597097.