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| [[Atrial fibrillation resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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| <small>Sinus rhythm</small> [[Image:Heart conduct sinus.gif|none|75px]]
| <small>Atrial fibrillation</small> [[Image:Heart conduct atrialfib.gif|none|100px]]
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{{Template:Atrial fibrillation}}
{{Template:Atrial fibrillation}}


{{CMG}}
{{CMG}} {{AE}} {{Anahita}}
 
==Overview==
[[Atrial fibrillation]] is [[diagnosis|diagnosed]] with the [[electrocardiogram]], an investigation performed routinely whenever irregular heartbeat is suspected.  Characteristic findings are the absence of [[P wave]]s, with unorganized electrical activity in their place, and irregularity of [[R-R interval]] due to irregular conduction of impulses to the [[ventricle]]s. If paroxysmal [[atrial fibrillation]] is suspected and 12-lead [[The electrocardiogram|ECG]] is normal, usage of a [[Holter monitor|24-hour ambulatory ECG monitor]] is recommended. Typical [[electrocardiogram]] findings in a [[patient]] with [[atrial fibrillation]] are absent [[P wave]]s, [[Irregularly irregular pulse|irregularly irregular]] [[Ventricle (heart)|ventricular]] response rate, and an [[Atrium (heart)|atrial]] rate that ranges from 400 to 700 BPM. A rapid, irregular, sustained, wide-[[QRS complex|QRS-complex]] [[tachycardia]] strongly suggests [[atrial fibrillation]] ([[AF]]) with conduction over an [[accessory pathway]] or [[atrial fibrillation]] ([[AF]]) with underlying [[bundle-branch block]].


==Electrocardiogram==
==Electrocardiogram==
{{main|Electrocardiogram}}
*[[The electrocardiogram|ECG]] is essential in [[diagnosis]] of [[atrial fibrillation]]. If paroxysmal [[atrial fibrillation]] is suspected and 12-lead [[The electrocardiogram|ECG]] is normal, usage of a [[Holter monitor|24-hour ambulatory ECG monitor]] is recommended.<ref name="pmid15464683">{{cite journal| author=Tse HF, Newman D, Ellenbogen KA, Buhr T, Markowitz T, Lau CP | display-authors=etal| title=Effects of ventricular rate regularization pacing on quality of life and symptoms in patients with atrial fibrillation (Atrial fibrillation symptoms mediated by pacing to mean rates [AF SYMPTOMS study]). | journal=Am J Cardiol | year= 2004 | volume= 94 | issue= 7 | pages= 938-41 | pmid=15464683 | doi=10.1016/j.amjcard.2004.06.034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15464683  }} </ref><ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref><ref name="pmid15155965">{{cite journal| author=Jabaudon D, Sztajzel J, Sievert K, Landis T, Sztajzel R| title=Usefulness of ambulatory 7-day ECG monitoring for the detection of atrial fibrillation and flutter after acute stroke and transient ischemic attack. | journal=Stroke | year= 2004 | volume= 35 | issue= 7 | pages= 1647-51 | pmid=15155965 | doi=10.1161/01.STR.0000131269.69502.d9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15155965  }} </ref>
*[[The electrocardiogram|ECG]] is helpful to identify:
** Rhythm (verify [[atrial fibrillation]] ([[AF]]))
** [[LV hypertrophy]]
** [[P-wave]] duration and morphology or fibrillary waves
** Preexcitation
** [[Bundle-branch block]]
** Prior [[MI]]
** Other [[Cardiac arrhythmia|atrial arrhythmias]]
** To measure and follow the [[RR interval|RR]], [[QRS]], and [[QT]] intervals in conjunction with [[antiarrhythmic agent]]
*[[The electrocardiogram|ECG]] also could be used as a predictor of [[atrial fibrillation]]. One of the strongest predictors is the P index, which is an estimation of disorganized [[atrium|atrial]] [[depolarization]].<ref name="pmid19781423">{{cite journal| author=Perez MV, Dewey FE, Marcus R, Ashley EA, Al-Ahmad AA, Wang PJ | display-authors=etal| title=Electrocardiographic predictors of atrial fibrillation. | journal=Am Heart J | year= 2009 | volume= 158 | issue= 4 | pages= 622-8 | pmid=19781423 | doi=10.1016/j.ahj.2009.08.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19781423  }} </ref>


Atrial fibrillation is diagnosed on an [[electrocardiogram]], an investigation performed routinely whenever irregular heart beat is suspected. Characteristic findings are the absence of P waves, with unorganized electrical activity in their place, and irregularity of R-R interval due to irregular conduction of impulses to the ventricles.
===Summary of Electrocardiographic Findings===
* Absent [[P wave]]s
* [[Irregularly irregular pulse|Irregularly irregular]] [[Ventricle (heart)|ventricular]] response rate. Regular [[RR]] intervals are possible in the presence of [[AV block]] or interference due to [[Ventricle (heart)|ventricular]] or junctional [[tachycardia]].
* An [[Atrium (heart)|atrial]] rate that ranges from 400 to 700 BPM.
* Sometimes lead V1 may look as though there is [[atrial flutter]]. This may be because the electrode overlies a portion of the [[Right atrium|RA]] with rhythmic activity. 
* Some authors believe that fine [[Electrocardiography|f waves]] (<.5 mm) are associated with [[Coronary heart disease|coronary artery disease]] and that coarse [[Electrocardiography|f waves]] are associated with [[Left atrial enlargement electrocardiogram|LA enlargement]] and [[rheumatic heart disease]].
* The [[Ventricle (heart)|ventricular]] rate is usually between 100 and 180 BPM.
* If the [[Atrium (heart)|atrial]] rate is greater than 200 BPM, then consider [[Wolff-Parkinson-White syndrome]] ([[WPW]]) or an [[accessory pathway]].
* In the presence of [[Atrioventricular dissociation|AV junctional disease]], the [[Ventricle (heart)|ventricular]] rate may be below 70 bpm.
* A rapid, irregular, sustained, wide-[[QRS complex|QRS-complex]] [[tachycardia]] strongly suggests [[atrial fibrillation]] ([[AF]]) with conduction over an [[accessory pathway]] or [[atrial fibrillation]] ([[AF]]) with underlying [[bundle-branch block]].
* [[Complete AV block]] is indicated by a slow [[Ventricle (heart)|ventricular]] rhythm with a regular [[RR interval]].
* In [[patients]] with electronic [[pacemaker]]s, [[diagnosis]] of [[atrial fibrillation]] ([[AF]]) may require temporary inhibition of the [[Artificial pacemaker|pacemaker]] to expose atrial fibrillary activity.
* [[Differential diagnosis]] includes an [[The electrocardiogram|ECG]] artifact such as a [[tremor]]. The oscillations in this case are largest in the [[limb leads]].


EKG is helpful to identify:
====When are Electrocardiograms Used for Screening?====
* Rhythm (verify AF)
The SAFE trial found that electronic software, [[primary care physician]]s and the combination of the two had the following [[Sensitivity (tests)|sensitivities]] and [[specificity (tests)|specificities]]:<ref name="pmid17604299">{{cite journal |author=Mant J, Fitzmaurice DA, Hobbs FD, ''et al'' |title=Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial |journal= |volume= |issue= |pages= |year=2007 |pmid=17604299 |doi=10.1136/bmj.39227.551713.AE}}</ref>
* [[LV hypertrophy]]
* Interpreted by software: [[sensitivity (tests)|sensitivity]] = 83%, [[specificity (tests)|specificity]] = 99%.
* [[P-wave]] duration and morphology or fibrillatory waves
* Interpreted by a [[primary care physician]]: [[sensitivity (tests)|sensitivity]]= 80%, [[specificity (tests)|specificity]] = 92%.
* [[Preexcitation]]
* Interpreted by a [[primary care physician]] with software: [[sensitivity (tests)|sensitivity]] = 92%, [[specificity (tests)|specificity]] = 91%.
* [[Bundle-branch block]]
* Prior [[MI]]
* Other atrial arrhythmias
* To measure and follow the [[RR]], [[QRS]], and [[QT]] intervals in conjunction with antiarrhythmic drug therapy


===Summary of Electrocardiographic findings===
If paroxysmal [[atrial fibrillation]] ([[AF]]) is suspected but the [[electrocardiogram]] shows a regular [[Pulse|rhythm]], episodes may be documented with the use of [[Holter monitor]]ing (continuous [[The electrocardiogram|ECG]] recording for 24 hours). If the [[symptoms]] are very infrequent, longer periods of continuous monitoring may be required.<ref name="pmid15155965">{{cite journal| author=Jabaudon D, Sztajzel J, Sievert K, Landis T, Sztajzel R| title=Usefulness of ambulatory 7-day ECG monitoring for the detection of atrial fibrillation and flutter after acute stroke and transient ischemic attack. | journal=Stroke | year= 2004 | volume= 35 | issue= 7 | pages= 1647-51 | pmid=15155965 | doi=10.1161/01.STR.0000131269.69502.d9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15155965  }} </ref>
#Absent [[P wave]]s
#Irregularly irregular ventricular response rate. Regular [[RR]] intervals are possible in the presence of [[AV block]] or interference due to ventricular or junctional [[tachycardia]].
#An atrial rate that ranges from 400 to 700 BPM.
#Sometimes lead V1 may look as though there is [[atrial flutter]]. This may be because the electrode overlies a portion of the [[RA]] with rhythmic activity. 
#Some authors believe that fine f waves (<.5 mm) are associated with coronary artery disease and that coarse F waves are associated with [[LA enlargement]] and [[rheumatic heart disease]].
#The ventricular rate is usually between 100 and 180 BPM.
#If the atrial rate is greater than 200 BPM, then consider [[WPW]] or an [[accessory pathway]].
#In the presence of AV junctional disease, the ventricular rate may be below 70 bpm.
#A rapid, irregular, sustained, wide-QRS-complex [[tachycardia]] strongly suggests AF with conduction over an [[accessory pathway]] or AF with underlying [[bundle-branch block]].
# [[Complete AV block]] is indicated by a slow ventricular rhythm with a regular RR interval.
#In patients with electronic pacemakers, diagnosis of AF may require temporary inhibition of the pacemaker to expose atrial fibrillatory activity.
#Differential diagnosis includes an [[EKG artifact]] such as a [[tremor]]. The oscillations in this case are largest in the limb leads.
 
====When are electrocardiograms used for screening?====
The SAFE trial found that electronic software, [[primary care physician]]s and the combination of the two had the following sensitivities and specificities:<ref name="pmid17604299">{{cite journal |author=Mant J, Fitzmaurice DA, Hobbs FD, ''et al'' |title=Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial |journal= |volume= |issue= |pages= |year=2007 |pmid=17604299 |doi=10.1136/bmj.39227.551713.AE}}</ref>:
* Interpreted by software: [[sensitivity (tests)|sensitivity]] = 83%, [[specificity (tests)|specificity]] = 99%
* Interpreted by a primary care physician: sensitivity = 80%, specificity = 92%
* Interpreted by a primary care physician with software: sensitivity = 92%, specificity = 91%
 
If paroxysmal AF is suspected but the [[electrocardiogram]] shows a regular rhythm, episodes may be documented with the use of [[Holter monitor]]ing (continuous ECG recording for 24 hours). If the symptoms are very infrequent, longer periods of continuous monitoring may be required.


----
----


 
Shown below is an [[The electrocardiogram|ECG]] showing rapid [[ventricle|ventricular]] response (short R-R interval) and no [[P wave]]s suggestive of [[atrial fibrillation]].
Shown below is an example of an EKG showing atrial fibrillation with rapid ventricular response. Left axis deviation.


[[Image:AFIB_01_jpg.jpg|center|500px]]
[[Image:AFIB_01_jpg.jpg|center|500px]]


Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
----
----


Shown below is an example of an EKG showing atrial fibrillation with rapid ventricular response. Left axis deviation.
Shown below is an [[The electrocardiogram|ECG]] showing a rapid [[ventricle|ventricular]] rate (short [[RR interval|R-R interval]]) and no [[P wave]]s suggestive of [[atrial fibrillation]].


[[Image:AFIB_02.jpg|center|500px]]
[[Image:AFIB_02.jpg|center|500px]]
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page


----
----


Shown below is an example of an EKG showing Atrial fibrillation with slow ventricular response. Bifascicular block [Right Bundle Branch Block + Left anterior fascicular block (LAFB)].
Shown below is an [[The electrocardiogram|ECG]] showing absent [[P wave]]s with a slow [[ventricle|ventricular]] response suggestive of [[atrial fibrillation]].


[[Image:AFIB_03.jpg|center|500px]]
[[Image:AFIB_03.jpg|center|500px]]


Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
----
----


Shown below is an example of an EKG showing Atrial fibrillation. Septal myocardial infarction (age indetermined)
Shown below is an [[The electrocardiogram|ECG]] showing absent [[P waves]] throughout the precordium, suggestive of [[atrial fibrillation]].


[[Image:AFIB_04.jpg|center|500px]]
[[Image:AFIB_04.jpg|center|500px]]


Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
----
----


;For more EKG examples of atrial fibrillation click [[Atrial fibrillation EKG examples|here]].
For more [[The electrocardiogram|ECG]] examples of [[atrial fibrillation]] click [[Atrial fibrillation EKG examples|here]].
 
==2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)<ref name="JanuaryWann2014">{{cite journal|last1=January|first1=C. T.|last2=Wann|first2=L. S.|last3=Alpert|first3=J. S.|last4=Calkins|first4=H.|last5=Cleveland|first5=J. C.|last6=Cigarroa|first6=J. E.|last7=Conti|first7=J. B.|last8=Ellinor|first8=P. T.|last9=Ezekowitz|first9=M. D.|last10=Field|first10=M. E.|last11=Murray|first11=K. T.|last12=Sacco|first12=R. L.|last13=Stevenson|first13=W. G.|last14=Tchou|first14=P. J.|last15=Tracy|first15=C. M.|last16=Yancy|first16=C. W.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000041}}</ref>==
 
* [[AF]] is a supraventricular [[tachyarrhythmia]] with uncoordinated [[atrium|atrial]] activation and consequently ineffective atrial contraction. [[ECG|Electrocardiogram (ECG)]] characteristics include:
:* Irregular [[RR interval|R-R intervals]] (when atrioventricular conduction is present)
:* Absence of distinct repeating [[P wave]]s
:* Irregular atrial activity
 
===Clinical Evaluation===
 
{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Electrocardiographic]] documentation is recommended to establish the diagnosis of [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
 
==Sources==
 
* [http://circ.ahajournals.org/content/early/2014/03/27/CIR.0000000000000041 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation]<ref name="JanuaryWann2014">{{cite journal|last1=January|first1=C. T.|last2=Wann|first2=L. S.|last3=Alpert|first3=J. S.|last4=Calkins|first4=H.|last5=Cleveland|first5=J. C.|last6=Cigarroa|first6=J. E.|last7=Conti|first7=J. B.|last8=Ellinor|first8=P. T.|last9=Ezekowitz|first9=M. D.|last10=Field|first10=M. E.|last11=Murray|first11=K. T.|last12=Sacco|first12=R. L.|last13=Stevenson|first13=W. G.|last14=Tchou|first14=P. J.|last15=Tracy|first15=C. M.|last16=Yancy|first16=C. W.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000041}}</ref>


===External EKG Sources===
*[http://www.emedu.org/ecg_lib/index.htm John Vozenilek's (MD) ECG Collection]
*[http://www.emedu.org/ecg_lib/index.htm John Vozenilek's (MD) ECG Collection]
*[http://www.ecgpedia.org ECGpedia]
*[http://www.ecgpedia.org ECGpedia]


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WS}}
[[CME Category::Cardiology]]


[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]
[[Category:Arrhythmia]]
[[Category:Electrophysiology]]
[[Category:Electrophysiology]]
[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
{{WH}}
{{WS}}

Latest revision as of 06:40, 13 October 2021
Resident
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]

Overview

Atrial fibrillation is diagnosed with the electrocardiogram, an investigation performed routinely whenever irregular heartbeat is suspected. Characteristic findings are the absence of P waves, with unorganized electrical activity in their place, and irregularity of R-R interval due to irregular conduction of impulses to the ventricles. If paroxysmal atrial fibrillation is suspected and 12-lead ECG is normal, usage of a 24-hour ambulatory ECG monitor is recommended. Typical electrocardiogram findings in a patient with atrial fibrillation are absent P waves, irregularly irregular ventricular response rate, and an atrial rate that ranges from 400 to 700 BPM. A rapid, irregular, sustained, wide-QRS-complex tachycardia strongly suggests atrial fibrillation (AF) with conduction over an accessory pathway or atrial fibrillation (AF) with underlying bundle-branch block.

Electrocardiogram

Summary of Electrocardiographic Findings

When are Electrocardiograms Used for Screening?

The SAFE trial found that electronic software, primary care physicians and the combination of the two had the following sensitivities and specificities:[5]

If paroxysmal atrial fibrillation (AF) is suspected but the electrocardiogram shows a regular rhythm, episodes may be documented with the use of Holter monitoring (continuous ECG recording for 24 hours). If the symptoms are very infrequent, longer periods of continuous monitoring may be required.[3]

Shown below is an ECG showing rapid ventricular response (short R-R interval) and no P waves suggestive of atrial fibrillation.

Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page

Shown below is an ECG showing a rapid ventricular rate (short R-R interval) and no P waves suggestive of atrial fibrillation.

Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page

Shown below is an ECG showing absent P waves with a slow ventricular response suggestive of atrial fibrillation.

Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page

Shown below is an ECG showing absent P waves throughout the precordium, suggestive of atrial fibrillation.

Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page

For more ECG examples of atrial fibrillation click here.

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[6]

  • Irregular R-R intervals (when atrioventricular conduction is present)
  • Absence of distinct repeating P waves
  • Irregular atrial activity

Clinical Evaluation

Class I
"1. Electrocardiographic documentation is recommended to establish the diagnosis of AF. (Level of Evidence: C) "

Sources

References

  1. ↑ Tse HF, Newman D, Ellenbogen KA, Buhr T, Markowitz T, Lau CP; et al. (2004). "Effects of ventricular rate regularization pacing on quality of life and symptoms in patients with atrial fibrillation (Atrial fibrillation symptoms mediated by pacing to mean rates [AF SYMPTOMS study])". Am J Cardiol. 94 (7): 938–41. doi:10.1016/j.amjcard.2004.06.034. PMID 15464683.
  2. ↑ Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee (2021). "Atrial fibrillation: diagnosis and management-summary of NICE guidance". BMJ. 373: n1150. doi:10.1136/bmj.n1150. PMID 34020968 Check |pmid= value (help).
  3. ↑ 3.0 3.1 Jabaudon D, Sztajzel J, Sievert K, Landis T, Sztajzel R (2004). "Usefulness of ambulatory 7-day ECG monitoring for the detection of atrial fibrillation and flutter after acute stroke and transient ischemic attack". Stroke. 35 (7): 1647–51. doi:10.1161/01.STR.0000131269.69502.d9. PMID 15155965.
  4. ↑ Perez MV, Dewey FE, Marcus R, Ashley EA, Al-Ahmad AA, Wang PJ; et al. (2009). "Electrocardiographic predictors of atrial fibrillation". Am Heart J. 158 (4): 622–8. doi:10.1016/j.ahj.2009.08.002. PMID 19781423.
  5. ↑ Mant J, Fitzmaurice DA, Hobbs FD; et al. (2007). "Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial". doi:10.1136/bmj.39227.551713.AE. PMID 17604299.
  6. ↑ 6.0 6.1 January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "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". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.

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