Table 16135.

Minimum and Additional Clinical Evaluation of Patients With Atrial Fibrillation

AF indicates atrial fibrillation; LV, left ventricular; MI, myocardial infarction; RV, right ventricular; LA, left atrial; and AV, atrioventricular. Type IC refers to the Vaughan Williams classification of antiarrhythmic drugs (see Table 2).
Minimum evaluation
1. History and physical examination, to define
• The presence and nature of symptoms associated with AF
• The clinical type of AF (first episode, paroxysmal, persistent, or permanent)
• The onset of the first symptomatic attack or date of discovery of AF
• The frequency, duration, precipitating factors, and modes of termination of AF
• The response to any pharmacological agents that have been administered
• The presence of any underlying heart disease or other reversible conditions (eg, hyperthyroidism or alcohol consumption)
2. Electrocardiogram, 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 RR, QRS, and QT intervals in conjunction with antiarrhythmic drug therapy
3. Chest radiograph, to evaluate
• The lung parenchyma, when clinical findings suggest an abnormality
• The pulmonary vasculature, when clinical findings suggest an abnormality
4. Echocardiogram, to identify
• Valvular heart disease
• Left and right atrial size
• LV size and function
• Peak RV pressure (pulmonary hypertension)
• LV hypertrophy
• LA thrombus (low sensitivity)
• Pericardial disease
5. Blood tests of thyroid function
• For a first episode of AF, when the ventricular rate is difficult to control, or when AF recurs unexpectedly after cardioversion
Additional testing
• One or several tests may be necessary
1. 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
2. Holter monitoring or event recording
• If diagnosis of the type of arrhythmia is in question
• As a means of evaluating rate control
3. Transesophageal echocardiography
• To identify LA thrombus (in the LA appendage)
• To guide cardioversion
4. Electrophysiological study
• To clarify the mechanism of wide-QRS-complex tachycardia
• To identify a predisposing arrhythmia such as atrial flutter or paroxysmal supraventricular tachycardia
• Seeking sites for curative ablation or AV conduction block/modification