Table 15. Minimum and Additional Clinical Evaluation in Patients With Atrial Fibrillation

Minimum evaluation  History and physical     examination To define: The presence and nature of symptoms associated with AF; clinical type of AF (first episode, paroxysmal, persistent, or permanent); onset of the 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 (eg hyperthyroidism or alcohol consumption)  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  Chest radiograph To evaluate: The lung parenchyma, when clinical findings suggest an abnormality; pulmonary vasculature, when clinical findings suggest an abnormality  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  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)  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  Holter monitoring or  event recording If diagnosis of the type of arrhythmia is in question; as a means of evaluating rate control  Transesophageal  echocardiography To identify LA thrombus (in the LA appendage); to guide cardioversion  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

AF = atrial fibrillation; LV = left ventricular; MI = myocardial infarction; RV = right ventricular; LA = left atrial; AV = atrioventricular; type IC = the Vaughn Williams classification of antiarrhythmic drugs.

Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines 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 European Society of Cardiology Committee for Practice Guidelines and Policy Conferences developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J. 2001;22:1852-1923.

Figure 15A. Antiarrhythmic Drug Therapy to Maintain Sinus Rhythm in Patients                        With Recurrent Paroxysmal or Persistent Atrial Fibrillation

HF = heart failure; CAD = coronary artery disease; LVH = left ventricular hypertrophy

*For adrenergic atrial fibrillation, beta-blockers or sotalol are the initial drugs of choice.
†Consider nonpharmacological options to maintain sinus rhythm if drug failure occurs.

Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines 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 European Society of Cardiology Committee for Practice Guidelines and Policy Conferences developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J. 2001;22:1852-1923.

Figure 15B. Pharmacological Management of Patients with Newly Discovered Atrial Fibrillation

Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines 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 European Society of Cardiology Committee for Practice Guidelines and Policy Conferences developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J. 2001;22:1852-1923.

Figure 15C. Pharmacological Management of Patients with Recurrent Persistent                        or Permanent Atrial Fibrillation

Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines 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 European Society of Cardiology Committee for Practice Guidelines and Policy Conferences developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J. 2001;22:1852-1923.